DENGUE EPIDEMIOLOGY AND CONTROL PROGRAM IN MALAYSIA

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DENGUE EPIDEMIOLOGY AND CONTROL PROGRAMIN
MALAYSIA

• DR ROSE NANI MUDIN
• DISEASE CONTROL DIVISION
• MINISTRY OF HEALTH
• 13 JAN 2009

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OUTLINES OF PRESENTATION

• Epidemiology of Dengue in Malaysia
• Dengue Mortality
• Control Activities Strategies
• Conclusion

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INCIDENCE RATE OF REPORTED DENGUE CASES IN
MALAYSIA (1981 - 2008)
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NUMBER OF REPORTED DENGUE FEVER AND DENGUE
HAEMORRHAGIC FEVER CASES IN MALAYSIA, 1995 2007
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DISTRIBUTION OF REPORTED DENGUE CASES IN MALAYSIA
BY EPIDEMIOLOGY WEEK (20062008)
Epid. Week
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COMPARISION OF DENGUE CASES BY STATE (2007
2008)
NO. OF CASES
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2008
2007
6
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THE DENGUE INCIDENCE RATE BY STATE (2008)
78
86
80
150
33
LABUAN
150
179
157
62
88
408
141
WPKL
334
110
MALAYSIA 178 cases/100,000population
118
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PATTERN OF DENGUE CASES
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RATIO OF DHF DF IN MALAYSIA 1998 2008
DHF DF RATIO
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PERCENTAGE DISTRIBUTION OF DENGUE CASES BY
LOCALITY IN MALAYSIA (1998 2008)
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DHF AND DF FATALITY RATES FOR MALAYSIA (1990-2008)
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DISTRIBUTION OF DENGUE DEATH CASES BY AGE GROUP
(1997 2007)
NO. OF CASES
YEAR
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FINDINGS OF DENGUE CASES ANALYSISFOR 2008
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DISTRIBUTION OF DENGUE CASES BY GENDER
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DISTIRBUTION OF DENGUE CASES BY AGE GROUP
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FINDINGS OF VEKPRO ANALYSIS FOR 2008 (Epid wk 1-
49)
State of Cases Fulfilling ClinicalCriteria of Positive Serology from All Cases with Results Cases Notified by Primary Care Clinics Cases Diagnosed 3 d from Onset Premises of Cases Fogged lt 5 d from Onset
Perlis 81.8 63.0 8.5 37.4 39.2
Kedah 65.9 55.2 1.1 46.5 31.5
P. Pinang 33.0 75.7 1.1 50.4 36.5
Perak 64.0 97.5 1.3 38.9 30.1
Selangor 95.8 91.7 5.7 31.7 13.5
WPKL 8.0 84.7 0.9 34.4 7.8
N. Sembilan 78.0 99.1 0.6 30.9 21.9
Melaka 65.7 99.5 0.2 35.9 29.9
Johor 93.7 84.3 0.2 32.7 19.6
Pahang 85.5 84.5 1.4 34.1 24.3
Terengganu 81.1 51.5 1.3 36.9 35.6
Kelantan 88.1 75.4 3.6 28.1 17.8
Sabah 45.5 79.1 3.3 35.2 18.2
WP Labuan 28.6 35.6 0 62.9 55.7
Putrajaya 56.8 100.0 14.5 25.5 7.8
Sarawak 37.1 90.3 10.9 42.0 18.2
MALAYSIA 74.2 85.4 3.4 34.5 18.8
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DENGUE MORTALITY ANALYSIS2008
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DENGUE MORTALITY

• 112 dengue deaths reported for 2008 (98 cases in
  2007
• Only 62 cases were reviewed by the state
  mortality review committee

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DISTRIBUTION OF DENGUE MORTALITY BY AGEGROUP
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DURATION BETWEEN TIME OF ONSET AND ADMISSION
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DURATION BETWEEN TIME OF ADMISSION AND DEATH
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CAUSE OF DEATH
DIAGNOSIS OF MORTALITY CASES
Fulfillment of WHO Case Definition (WHO 1997) Percentage of Cases
DF 0
DHF 11
DSS 89
Immediate Cause of death Percentage of Cases
Shock Syndrome 61.8
End/Multi organ failure 40.0
Severe bleeding from GIT/DIVC/Thrombocytopenia 32.7
ARDS 10.9
Sepsis (including Nosocomial infection) 10.9
Others (specify) Hyperkalemia with ARF 12.7
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CONTRIBUTING FACTORS FOR DENGUE MORTALITY
N0. CONTRIBUTING FACTORS
1. PATIENT CAME IN ALREADY TOO ILL 47.3
2. DELAY IN DIAGNOSIS/ ASSESSMENT OF SEVERITY
Low index of suspicion 36.4
Delay in review by doctor 14.5
Late referral 9.1
Results delayed/not traced/not reviewed 7.3
Infrequent investigation ordered 7.3
Others 16.4
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CONTRIBUTING FACTORS FOR DENGUE MORTALITY
N0. CONTRIBUTING FACTORS
3. INADEQUATE MONITORING/TREATMENT
Inadequate fluid resuscitation 21.8
Failure to recognize DSS 20.0
Insufficient blood products given 18.2
Inadequate monitoring of vital signs 16.4
Overloading/pulmonary oedema 16.4
Delay in seeking ICU care 14.5
Inadequate monitoring of FBC 10.9
DIVC not suspected/recognized 1.8
4. CO MORBID CONDITIONS
Obesity 14.5
Extremes of age (lt1yr / gt60yrs) 9.1
Others Uncontrolled DM/HPT Hepatitis, Fits 18.2
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53 of the death were preventable
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Key Components of Dengue Control Strategy

• Early diagnosis and treatment
• Training of frontliners
• Health education to public on importance of early
  diagnosis and treatment
• Active case detection in outbreak localities
• Prompt notification
• Within 24 hours
• By phone
• Nearest District Health Office
• Case Investigation within 24 hours
• Prompt vector control response
• Within 24 hours of notification
• Fogging within 200 m radius
• 400 m if outbreak locality
• Quality Assurance Program -Dengue Outbreak
  Control Index (DOCI) 100 outbreak controlled
  within 14 days

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Key Components of Dengue Control Strategy

• Proper Case Management
• CPG- The Management Of Dengue Infection In
  Adult/Children (2nd Edition)
• All dengue death are audited immediately.
• Appropriate remedial actions are taken by the
  relevant parties and report to be sent to the
  Disease Control Division within 2 weeks
• Health Education And Community Mobilization
• Production of health materials/ mass media
• Guidelines on health education and community
  mobilization activities in outbreak localities
• Guidelines on COMBI For Dengue Prevention and
  Control

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CHALLENGES IN THE DENGUE PREVENTION ACTIVITIES

• Health seeking behavior of the dengue patient
• Only 4 of cases were from the clinic and
  majority from hospital
• 50 of the dengue mortality cases were admitted
  on day 4 or 5 after onset - delay in seeking
  treatment
• 47 of dengue mortality cases came in already ill
• Difficult to break the dengue virus transmission
• Only 35 of patient diagnosed within 3 days from
  the onset of illness
• Only 19 of dengue cases residence were fogged
  within 5 days of onset of illness
• Thus other patients infected with the dengue
  virus may still transmit the disease

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CHALLENGES IN THE DENGUE PREVENTION ACTIVITIES

• Low index of suspicion of dengue cases by the
  attending doctors
• Delayed notification
• Delay in giving appropriate treatment
• Lack in community cooperation and participation
  in the dengue prevention and control activities

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CONCLUSION-1

• To strengthen the implementation of dengue
  prevention and control measure (to be alert and
  responsive)
• Ensure effective and efficient performance of the
  control activities through
• Monitoring supervision
• Analysis of data at district, state, and MOH level

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CONCLUSION-2

• Strengthen the prevention and control activities
  at district and state level
• Facilitate training for healthcare workers to
  increase knowledge and skills on the dengue
  management and vector control
• Continuous monitoring of dengue status and
  mortality at all levels, as to address
  uncontrolled situation of the disease

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THANK YOU FOR YOUR ATTENTION