Staphylococcal poisoning during a village festival, Medina, Misamis Oriental, Philippines in 2014.

INTRODUCTION: On 18 August 2014, cases of food poisoning in San Vicente Village were reported to the Event-Based Surveillance & Response Unit of the Philippine Department of Health. An investigation was conducted to identify the implicated source, describe the outbreak and evaluate the risk factors. METHODS: A case-control study was conducted. A suspected case was a previously well individual of Medina who attended the village festival and developed abdominal pain and vomiting with or without nausea, diarrhoea and fever from 18 to 19 August. A confirmed case was a suspected case with a rectal swab positive for bacterial culture. Rectal swabs, water and food samples were sent to the national reference laboratories. Food source and consumption interviews and environmental inspections were conducted. RESULTS: Sixty-four cases and 123 unmatched controls were identified. The median incubation period was 1 hour 15 minutes. Five cases (8%) were positive for Staphylococcus aureus, one (2%) for Aeromonas hydrophilia and one (2%) for Shigella boydii. One (14%) water sample was positive for Aeromonas spp. Of the collected food samples, beef steak was positive for Staphylococcus aureus. Risk factors were consumption of Filipino-style beef stew (odds ratio [OR]: 6.62; 95% confidence interval [CI]: 2.90-15.12) and stir-fried noodles (OR: 3.15; 95% CI: 1.52-6.50). Prolonged serving time and improper food storage were noted. DISCUSSION: In this foodborne outbreak, Staphylococcus aureus was the likely causative agent. Meals were contaminated due to improper food handling practices. We recommend that a policy be created to mandate that village-appointed food handlers undergo food safety training.

Is your drinking-water safe? A rotavirus outbreak linked to water refilling stations in the Philippines, 2016.

INTRODUCTION: In April 2016, the Department of Health in Zamboanga Peninsula reported an increase in the number of acute gastroenteritis cases reported from Zamboanga City. An epidemiologic investigation was conducted to verify the existence of an outbreak, determine source/mode of transmission and recommend control measures. METHODS: A line list of cases was compiled from the 11 hospitals within Zamboanga City and a case-series study was conducted. Suspected cases were any persons from Zamboanga City who had three or more episodes of acute diarrhoea within 24 hours from 15 March to 29 May 2016. Confirmed cases were suspected cases with active symptoms during the investigation who had a stool sample collected with rotavirus detected. Water samples were also collected for viral detection. RESULTS: There were 2936 suspected cases with 22 deaths (case fatality rate: 0.75%), an age range of 8 days to 89 years (median: 2 years), with those aged less than 5 years the most affected age group (1903/2936, 65%). The majority were males (1549/2936, 53%). From the 138 active case patients included in the case-series study, the majority reported contact with a family member who had diarrhoea (89/138, 64%) and using water refilling stations as their major source of drinking-water (88/134, 64%). Of the 93 stool specimens collected, 56 (60%) were positive for rotavirus. Five samples from water refilling stations where case patients reported collecting drinking-water were all positive for rotavirus. DISCUSSION: Strict regulation of water refilling stations and boiling drinking-water in households were implemented, immediately controlling the outbreak. After complying with all the requirements set by the Department of Health, a water safety certificate was awarded to Zamboanga City in September 2018.

Risk assessment of Ebola Reston virus in humans in the Philippines.

OBJECTIVE: There have been five documented outbreaks of Ebola Reston virus (RESTV) in animals epidemiologically linked to the Philippines. This assessment was conducted to determine the risk of RESTV occurring in humans in the Philippines and its potential pathogenicity in humans. METHODS: The World Health Organization Rapid Risk Assessment of Acute Public Health Events Manual was used for the assessment. A literature review was done and a risk assessment matrix was used for the risk characterization of the outbreaks in the Philippines. The risk assessment was conducted by the Philippines Field Epidemiology Training Program. RESULTS: The risk of RESTV occurring in humans in the Philippines and its potential pathogenicity in humans were both assessed as moderate. Animals involved in RESTV outbreaks in the Philippines were non-human primates and domestic pigs. The presence of RESTV in pigs poses a possibility of genetic evolution of the virus. Although RESTV has been identified in humans, there was no death or illness attributed to the infection. The Philippines Inter-agency Committee on Zoonoses oversees collaboration between the animal and human health sectors for the prevention and control of zoonoses. However, there is no surveillance of risk animals or previously affected farms to monitor and facilitate early identification of cases. DISCUSSION: The moderate risk of RESTV recurring among humans in the Philippines and its potential pathogenicity in humans reinforces the need for early detection, surveillance and continued studies of RESTV pathogenesis and its health consequences. The One Health approach, with the involvement and coordination of public health, veterinary services and the community, is essential in the detection, control and management of zoonosis.

Consumption of barracuda in the Caribbean Sea linked to ciguatera fish poisoning among Filipino seafarers.

INTRODUCTION: Ciguatera fish poisoning (CFP) is common in tropical and subtropical waters. On 13 November 2015, eight Filipino seafarers from a cargo ship sailing in the Caribbean Sea experienced a range of symptoms after consuming a barracuda. Upon their return to the Philippines, an investigation was conducted to describe the cases. METHODS: A case-series was conducted. A CFP case was defined as a previously well individual on the ship who developed at least one gastrointestinal symptom and at least one neurologic manifestation after eating barracuda on 13 November 2015. All cases were admitted to hospital in Manila, Philippines and were interviewed using a standard questionnaire. Urine and serum samples of cases were collected for ciguatoxin (CTX) testing by radiological and receptor-binding assay. RESULTS: Eight of the 25 seafarers on the ship ate the barracuda; all eight met the CFP case definition. The age of cases ranged from 37 to 58 years (median: 47 years) and all were males. Onset of symptoms ranged from 1 to 3 hours (median: 2 hours) from the time of ingestion of the barracuda. All cases experienced gastrointestinal (nausea, vomiting, diarrhoea) and neurologic (temperature allodynia, itchiness) symptoms but no cardiovascular manifestations. Urine and serum specimens of all eight cases showed CTX below the detection limit. DISCUSSION: The Philippines Epidemiology Bureau recommended that the Philippine Maritime Authority include CTX poisoning and its health risks in seafarers' training to prevent future cases of CFP. The Event-based Surveillance and Response system will continue to provide a mechanism for the reporting and appropriate management of CFP cases.

Epidemic hysteria following the National School Deworming Day, Zamboanga Peninsula, Philippines, 2015.

INTRODUCTION: In July 2015, the Philippines conducted a school-based mass drug administration using albendazole for soil-transmitted helminths infection. Reports of adverse events were subsequently made through the event-based surveillance system, mostly from the Zamboanga Peninsula on the island of Mindanao. A team from the Epidemiology Bureau investigated the reports of adverse events following mass drug administration (AEFMDA). METHODS: Five schools were identified for the investigation which comprised an unmatched case-control study, key informant interviews and laboratory examinations. AEFMDA cases were students who had sudden onset of abdominal pain, vomiting, diarrhoea, loss of consciousness, headache or dizziness within 24 hours after intake of deworming tablet; controls were healthy students who did not develop signs and symptoms after deworming. RESULTS: Most (85%) of the 7313 AEFMDA cases reported nationwide were from Zamboanga Peninsula. Most reports were made after rumours of deaths following deworming and of the use of expired drug were spread through the region. Many parents sent their children to hospital, even if asymptomatic. The case-control study found that being an AEFMDA case was associated with no history of previous deworming (odds ratio = 4.08, 95% confidence interval: 1.77-9.42). DISCUSSION: The investigation concluded that epidemic hysteria was the cause of the increased number of AEFMDA cases in the Zamboanga Peninsula. The false information, aggravated by social media, caused panic and an increase in reporting. Some cases had no history of deworming, and they may not have been aware that albendazole is safe and that side-effects are expected. Risk communication before, during and after future national deworming programmes are recommended to prevent unnecessary reporting of AEFMDA.

A retrospective cohort study on cassava food poisoning, Santa Cruz, Davao del Sur, Philippines, October 2015.

OBJECTIVE: On 2 October 2015, the Event-Based Surveillance and Response Unit of the Department of Health (DOH), Philippines received a report of foodborne illness cases in Santa Cruz, Davao del Sur. A team from DOH was sent to conduct an investigation to identify the implicated source and determine risk factors. METHODS: A retrospective cohort study was done. A suspect case was defined as a previously well individual in Compound A, Santa Cruz who developed abdominal pain, headache, dizziness, diarrhoea or vomiting on either 1 or 2 October 2015. A confirmed case was a suspect case positive for cyanide in urine. Family members who prepared the food were interviewed. Urine specimens were collected to test for thiocyanate, and cassava tuber and soil samples were tested for cyanide and other chemicals. RESULT: Fourteen cases with two deaths were identified (case fatality ratio: 14%). All cases consumed cassava on 1 October 2015 except for one child who spat it out. Urine samples were all negative (36, 100%) for thiocyanate so there were no confirmed cases. The cassava sample had a cyanide level of 68.94 ug/g and was identified as bitter cassava, also known as a potentially dangerous kind. Insufficient food preparation was noted. In the retrospective cohort study, intake of cassava (RR = 208, 95% CI: 19.94-2169.32) was associated with the illness. DISCUSSION: This study identified insufficiently processed cassava root crop as the source of the foodborne illness. The cassava consumed was the bitter variety that contains greater than 50 ug/g of hydrogen cyanide and requires thorough preparation before consumption. Community education was provided on identifying and preparing cassava appropriately.

Investigation of a measles outbreak in Cordillera, Northern Philippines, 2013.

INTRODUCTION: Measles is a highly infectious viral illness that remains one of the leading causes of death among children worldwide. In the Philippines, decreasing routine vaccination coverage from 2007 to 2011 led to local measles outbreaks. A team investigated a measles outbreak reported in Cordillera of the Philippines in May 2013. METHODS: Measles case data with symptom onset from 2 February to 27 May 2013 were obtained from official sources and verified on site. Data included age, sex, residential address, signs and symptoms and vaccination status. Active case-findings were also conducted for contacts of these cases. The living environments of the cases were investigated. A survey was conducted with the cases and caregivers to understand their knowledge and attitudes about measles. RESULTS: There were 50 measles cases identified with an age range from six months to 32 years (median: 16 years). Thirty-two were male (64%). Twenty (40%) were hospitalized with one death. Thirty-two (64%) cases were laboratory confirmed, and 36 (72%) received a single dose of measles vaccine. Overcrowded living environments were observed among many cases. The majority of respondents (46/48, 96%) knew about measles, but there were misconceptions about the cause of measles and how it can be prevented and managed. CONCLUSION: This measles outbreak occurred in an area with low immunization coverage. Achieving 95% measles immunization coverage and strengthening routine immunization strategies to address high-risk populations are recommended. Also, we recommend health education campaigns to include components that address misconceptions about measles.

Contact tracing the first Middle East respiratory syndrome case in the Philippines, February 2015.

BACKGROUND: Middle East respiratory syndrome (MERS) is an illness caused by a coronavirus in which infected persons develop severe acute respiratory illness. A person can be infected through close contacts. This is an outbreak investigation report of the first confirmed MERS case in the Philippines and the subsequent contact tracing activities. METHODS: Review of patient records and interviews with health-care personnel were done. Patient and close contacts were tested for MERS-coronavirus (CoV) by real time-polymerase chain reaction. Close contacts were identified and categorized. All traced contacts were monitored daily for appearance of illness for 14 days starting from the date of last known exposure to the confirmed case. A standard log sheet was used for symptom monitoring. RESULTS: The case was a 31-year-old female who was a health-care worker in Saudi Arabia. She had mild acute respiratory illness five days before travelling to the Philippines. On 1 February, she travelled with her husband to the Philippines while she had a fever. On 2 February, she attended a health facility in the Philippines. On 8 February, respiratory samples were tested for MERS-CoV and yielded positive results. A total of 449 close contacts were identified, and 297 (66%) were traced. Of those traced, 15 developed respiratory symptoms. All of them tested negative for MERS. DISCUSSION: In this outbreak investigation, the participation of health-care personnel in conducting vigorous contact tracing may have reduced the risk of transmission. However, being overly cautious to include more contacts for the outbreak response should be further reconsidered.

Investigation of chikungunya fever outbreak in Laguna, Philippines, 2012.

BACKGROUND: In July 2012, the Philippines National Epidemiology Center received a report of a suspected chikungunya fever outbreak in San Pablo City, Laguna Province, the first chikungunya cases reported from the city since surveillance started in 2007. We conducted an outbreak investigation to identify risk factors associated with chikungunya. METHODS: A case was defined as any resident of Concepcion Village in San Pablo City who had fever of at least two days duration and either joint pains or rash between 23 June and 6 August 2012. Cases were ascertained by conducting house-to-house canvassing and medical records review. An unmatched case-control study was conducted and analysed using a multivariate logistic regression. An environmental investigation was conducted by observing water and sanitation practices, and 100 households were surveyed to determine House and Breteau Indices. Human serum samples were collected for confirmation for chikungunya IgM through enzyme-linked immunosorbent assay. RESULTS: There were 98 cases identified. Multivariate analysis revealed that having a chikungunya case in the household (adjusted odds ratio [aOR]: 6.2; 95% confidence interval [CI]: 3.0-12.9) and disposing of garbage haphazardly (aOR: 2.7; 95% CI: 1.4-5.4) were associated with illness. House and Breteau Indices were 27% and 28%, respectively. Fifty-eight of 84 (69%) serum samples were positive for chikungunya IgM. CONCLUSION: It was not surprising that having a chikungunya case in a household was associated with illness in this outbreak. However, haphazard garbage disposal is not an established risk factor for the disease, although this could be linked to increased breeding sites for mosquitoes.

Availability of safe drinking-water: the answer to cholera outbreak? Nabua, Camarines Sur, Philippines, 2012.

BACKGROUND: In May 2012, there were increasing diarrhoea cases and deaths reported from Nabua, Camarines Sur to the Philippines event-based surveillance system. An investigation was conducted to identify risk factors and determine transmission dynamics. METHODS: A suspected case was defined as a resident of Nabua with at least three episodes of watery diarrhoea per day from 16 March to 22 June 2012. A confirmed case was defined as a suspected case positive for Vibrio cholerae. An environmental investigation was conducted and rectal swabs and water samples sent to the national reference laboratory for bacterial isolation. A 1:2 case-control study matching for age and sex was conducted. Data were analysed using Epi Info. RESULTS: There were 309 suspected cases with two deaths, and the most affected age group was children under five years (45%). Eight cases were positive for Vibrio cholerae Ogawa El Tor and one for Non-01. Water samples were positive for faecal coliforms and Aeromonas caviae. The case-control study showed that cases had a higher odds than controls of using unchlorinated water sources (odds ratio [OR] = 3.6; 95% confidence interval [CI]:1.6-8.5) and having toilets located within 20 m of a septic tank (OR = 2.7; 95% CI: 1.4-5.3). In multivariate analysis, the only significant factor was drinking from piped water (OR = 0.21; 95% CI: 0.09-0.49). DISCUSSION: In this cholera outbreak, drinking-water from unchlorinated wells was a significant risk factor. Future cholera control efforts should include not just improving water and sanitation systems but also intensified behaviour change campaigns.

Chelonitoxism outbreak caused from consuming turtle, Eastern Samar, Philippines, August 2013.

BACKGROUND: On 21 August 2013, the Event-based Surveillance and Response system of the Department of Health, Philippines captured a foodborne illness event among residents of a coastal village in Eastern Samar, Philippines. The suspected cause was the consumption of a sea turtle found near the village. A team from the Department of Health was sent to conduct an outbreak investigation. METHODS: A case was defined as any person in Arteche, Eastern Samar, who developed dry mouth and burning sensation in the throat from 15 August to 27 August, 2013. Severity of the disease was classified as mild, moderate or severe. We conducted records review, environmental investigation, interviews of key informants and a retrospective cohort study. RESULTS: Sixty-eight cases were identified; four died (case fatality rate = 6%). All cases had a history of turtle meat consumption. Dose-dependent relationship was noted between amount of turtle meat consumed and the risk of illness. In the cohort study, consumption of turtle meat and turtle meat soup were associated with illness. CONCLUSION: This study identified turtle meat as the source of this foodborne outbreak and emphasized the dangers of consuming turtle meat. Other reported cases of turtle meat poisoning in the Philippines suggest that turtle consumption is an ongoing practice in the country. By publishing information about sea turtle poisoning outbreaks in the Philippines, we hope to raise awareness of the potential severe health effects from ingesting these endangered sea creatures.

Lethal paralytic shellfish poisoning from consumption of green mussel broth, Western Samar, Philippines, August 2013.

BACKGROUND: In July 2013, the Philippines' Event-Based Surveillance & Response Unit received a paralytic shellfish poisoning (PSP) report from Tarangnan, Western Samar. A team from the Department of Health conducted an outbreak investigation to identify the implicated source and risk factors in coastal villages known for green mussel production and exportation. METHODS: A case was defined as a previously well individual from Tarangan, Western Samar who developed gastrointestinal symptoms and any motor and/or sensory symptoms after consumption of shellfish from 29 June to 4 July 2013 in the absence of any known cause. The team reviewed medical records, conducted active case finding and a case-control study. Relatives of cases who died were interviewed. Sera and urine specimens, green mussel and seawater samples were tested for saxitoxin levels using high performance liquid chromatography. RESULTS: Thirty-one cases and two deaths were identified. Consumption of > 1 cup of green mussel broth was associated with being a case. Seawater sample was positive for Pyrodinium bahamense var. compressum and green mussel samples were positive for saxitoxin. Inspection revealed villagers practice open defecation and improper garbage disposal. CONCLUSION: This PSP outbreak was caused by the consumption of the green mussel broth contaminated by saxitoxin. As a result of this outbreak, dinoflagellate and saxitoxin surveillance was established, and since the outbreak, there have been no harmful algal blooms event or PSP case reported since. A "Save Cambatutay Bay" movement, focusing on proper waste disposal practice and clean-up drives has been mobilized.

A community-based gastroenteritis outbreak after Typhoon Haiyan, Leyte, Philippines, 2013.

BACKGROUND: Three weeks after Typhoon Haiyan, an increasing number of acute gastroenteritis cases were reported in Kananga, Leyte, an area where evacuated residents had returned home two days after the disaster. An outbreak investigation was conducted to identify the source and risk factors associated with the increase of gastroenteritis. METHODS: A case was defined as any person in Kananga who developed acute diarrhoea (≥ 3 times/24 hours) and any of the following symptoms: fever, nausea, vomiting or abdominal pain from 11 November 2013 to 10 December 2013. Active case finding was conducted by reviewing medical records, and a case-control study was conducted. Rectal swabs and water samples were tested for bacteriological examination. RESULTS: One hundred and five cases were identified. Multivariate analysis revealed that consumption of untreated drinking-water was associated with illness (adjusted odds ratio: 18.2). Both rectal swabs and municipal water samples tested positive for Aeromonas hydrophila. On inspection of the municipal water system, breaks in the distribution pipes were found with some submerged in river water. CONCLUSION: This acute gastroenteritis outbreak was most likely caused by Aeromonas hydrophila and transmitted through a contaminated water source. This study highlights that areas less damaged by a disaster that do not require ongoing evacuation centres can still have acute gastroenteritis outbreaks. All affected areas should be monitored during a disaster response, not just those with evacuation centres. Boiling or chlorinating of water should also be recommended for all areas affected by disaster.

Outbreak of henipavirus infection, Philippines, 2014.

During 2014, henipavirus infection caused severe illness among humans and horses in southern Philippines; fatality rates among humans were high. Horse-to-human and human-to-human transmission occurred. The most likely source of horse infection was fruit bats. Ongoing surveillance is needed for rapid diagnosis, risk factor investigation, control measure implementation, and further virus characterization.

An assessment of disaster-related mortality post-Haiyan in Tacloban City.

INTRODUCTION: Tacloban City was seriously affected by Typhoon Haiyan with 2321 deaths distributed across its 138 villages and subvillages. In January 2014, a team from the Department of Health conducted a mortality assessment to identify risk factors for deaths that occurred during Typhoon Haiyan. METHODS: A retrospective case-control study was conducted in the four coastal villages in Tacloban City with the highest numbers of typhoon-associated deaths. A case was defined as a person who died in Tacloban City during Typhoon Haiyan and whose body was recovered and identified. Controls were selected from surviving family members of cases. Information about typhoon-related knowledge, attitudes and practices of the cases was collected using a standardized questionnaire. RESULTS: There were 100 cases and 100 controls included in the study. The cause of death for all cases was drowning, and all bodies were found inside or near their house. Multivariate analysis identified that the significant risk factors for mortality due to Haiyan were not evacuating before the storm hit (odds ratio [OR] = 10.0; 95% confidence interval [CI]: 3.8-29.1) and exiting their house during the storm (OR = 3.6; 95% CI: 1.9-7.1). Proxies reported that all cases had heard about the coming typhoon, but that 88% did not understand the message about the storm surge. Ninety-five per cent of cases did not evacuate because they did not expect the magnitude of storm. CONCLUSION: Warning messages delivered before and during emergencies should be conveyed in terms understood by the population at risk. We recommend that the results from this study be used to develop more effective messages to be used before future disasters.

Rapid health assessments of evacuation centres in areas affected by Typhoon Haiyan.

INTRODUCTION: Typhoon Haiyan caused thousands of deaths and catastrophic destruction, leaving many homeless in Region 8 of the Philippines. A team from the Philippine Field Epidemiology Training Program conducted a rapid health assessment survey of evacuation centres severely affected by Haiyan. METHODS: A descriptive study was conducted whereby a convenience sample of evacuation centres were assessed on the number of toilets per evacuee, sanitation, drinking-water, food supply source and medical services. RESULTS: Of the 20 evacuation centres assessed, none had a designated manager. Most were located in schools (70%) with the estimated number of evacuees ranging from 15 to 5000 per centre. Only four (20%) met the World Health Organization standard for number of toilets per evacuee; none of the large evacuation centres had even half the recommended number of toilets. All of the evacuation centres had available drinking-water. None of the evacuation centres had garbage collection, vector control activities or standby medical teams. Fourteen (70%) evacuation centres had onsite vaccination activities for measles, tetanus and polio virus. Many evacuation centres were overcrowded. CONCLUSION: Evacuation centres are needed in almost every disaster. They should be safely located and equipped with the required amenities. In disaster-prone areas such as the Philippines, schools and community centres should not be designated as evacuation centres unless they are equipped with adequate sanitation services.

Management of the dead in Tacloban City after Typhoon Haiyan.

INTRODUCTION: The post-disaster management of the dead involves a series of steps including on-site identification, transfer, storage and examination of bodies and delivery to families for burial. Two weeks after Typhoon Haiyan, a team from the Department of Health (DOH) was tasked with identifying the dead in Tacloban City. METHODS: A suitable site for the collection of bodies was identified and an algorithm and standard data collection form developed. The retrieval of bodies was coordinated with the Bureau of Fire Protection personnel. Upon receipt of a body, two team members conducted a systematic external examination. Findings were documented, photos were taken and each body was assigned a unique number. RESULTS: The DOH team examined 128 bodies. Of these, the majority (86%) were complete bodies; 95% were decomposed and two were skeletonized. Two thirds (66%) were adults, sex was identifiable for 92%, and the male to female ratio was 1:1.4. The majority of adults were females. Only 11% were presumptively identified from documents in clothing; 89% remained unidentified. CONCLUSION: From the limited setting of this study, we describe the process of rapid body processing post-Haiyan. We prioritized rapid processing over more technically complicated means of identification, including DNA testing. Our protocol showed a dignified and efficient way of identifying corpses. As local and regional laboratory capacity increases in the Philippines, the collection of DNA specimens may become part of the identification algorithm.

An assessment of the case notification system 16 months after Typhoon Haiyan in Region 8, the Philippines.

INTRODUCTION: The Philippines Department of Health uses the Philippine Integrated Disease Surveillance and Response (PIDSR) system to monitor 25 diseases and syndromes that have the potential to cause outbreaks. The focus of this system is to strengthen the capacity of local government units for early detection and response to outbreaks. After Typhoon Haiyan, routine disease surveillance activities were suspended at the Epidemiology and Surveillance Units (ESUs) at the city and provincial levels, as well as laboratory services; surveillance resumed as soon as local conditions allowed. METHOD: We conducted an assessment of PIDSR in March 2015, 16 months post-Haiyan, in Region 8, the most heavily affected region. We used key informant interviews and a review of data from the system to assess the core surveillance and support functions. RESULTS: All ESUs reported they were performing all surveillance core functions, although laboratory confirmation needed to be strengthened at the regional reference laboratory. Access to working communication equipment also needed improvement as did timeliness and completeness of reporting. DISCUSSION: Assessment of surveillance activities, resources and quality should be conducted post-disaster. The strength and operations of the disease surveillance system usually requires support from the local, regional and national governments, especially if there are legal mandates and legislation that includes the system in disaster planning. Regular monitoring of the system is recommended to ensure stability, system development, increased outbreak detection and fewer morbidities and fatalities.

Fireworks-related injury surveillance in the Philippines: trends in 2010-2014.

Analysis of the annual fireworks-related injury surveillance data collected by the Philippines Department of Health (DOH) in 2010-2014 was conducted to describe the profile of such injuries in the Philippines. Surveillance data were collected from DOH's Online National Electronic Injury Surveillance System and analysed. A case was defined as any person who had sustained injury from fireworks in any form within the 16-day surveillance period (21 December to 5 January) and had presented to any of the 50 sentinel hospitals. Of the 4649 cases, there were 4706 fireworks-related injuries involving 5076 anatomic sites in 2010-2014. A significant decrease of cases in 2014 was observed when compared with the previous study years (P = 0.02). The number of cases peaked at public holidays. Males (80%) were more commonly injured, and children aged 5 to 14 years were primarily affected (47%). Ignition of illegal fireworks accounted for half (50%) of the injuries; most injuries (68%) occurred in street settings. The majority of injuries (57%) were sustained by fireworks igniters. The most common anatomic injury sites were hands (44%), legs (21%) and eyes (14%). Illegal fireworks were related to 100% (4/4) of the deaths and 49% (105/214) of the cases who needed amputations. Fireworks-related injuries declined significantly in 2014. Public awareness campaigns may have contributed to reducing the injury occurrences. As illegal fireworks accounted for all deaths and more than half of the amputations, law enforcement should be directed towards preventing importing, distributing and using illegal fireworks.