1. DENGUE EPIDEMIOLOGY AND CONTROL PROGRAM IN MALAYSIA
DR ROSE NANI MUDIN
DISEASE CONTROL DIVISION
MINISTRY OF HEALTH
13 JAN 2009

2. OUTLINES OF PRESENTATION
Epidemiology of Dengue in Malaysia
Dengue Mortality
Control Activities Strategies
Conclusion

3. INCIDENCE RATE OF REPORTED DENGUE CASES IN MALAYSIA (1981 - 2008)3

4. NUMBER OF REPORTED DENGUE FEVER AND DENGUE HAEMORRHAGIC FEVER CASES IN MALAYSIA, 1995 – 2007

5. DISTRIBUTION OF REPORTED DENGUE CASES IN MALAYSIA BY EPIDEMIOLOGY WEEK (2006–2008)
Epid. Week 5

6. COMPARISION OF DENGUE CASES BY STATE (2007 & 2008)
NO. OF CASES
2008 6
2007 6

7. 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

8. PATTERN OF DENGUE CASES

9. RATIO OF DHF : DF IN MALAYSIA
1998 – 2008
DHF : DF RATIO 9 9

10. PERCENTAGE DISTRIBUTION OF DENGUE CASES BY LOCALITY IN MALAYSIA (1998 – 2008)10 10

11. % 11 11 11

12. DHF AND DF FATALITY RATES FOR MALAYSIA (1990-2008)

13. DISTRIBUTION OF DENGUE DEATH CASES BY AGE GROUP (1997 – 2007)
NO. OF CASES
YEAR 13

14. FINDINGS OF DENGUE CASES ANALYSIS FOR 200814

15. DISTRIBUTION OF DENGUE CASES BY GENDER15

16. DISTIRBUTION OF DENGUE CASES BY AGE GROUP16 16

17. 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
Diagnosed
≤ 3 d from
Onset
% Premises
of Cases
Fogged < 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
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
32.7
19.6
Pahang
85.5
84.5
1.4
34.1
24.3
Terengganu
81.1
51.5
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
62.9
55.7
Putrajaya
56.8
100.0
14.5
25.5
Sarawak
37.1
90.3
10.9
42.0
MALAYSIA
74.2
85.4
3.4
34.5
18.8 17

18. DENGUE MORTALITY ANALYSIS 200818

19. DENGUE MORTALITY 112 dengue deaths reported for 2008 (98 cases in 2007
Only 62 cases were reviewed by the state mortality review committee 19

20. DISTRIBUTION OF DENGUE MORTALITY BY AGEGROUP20

21. DURATION BETWEEN TIME OF ONSET AND ADMISSION21

22. DURATION BETWEEN TIME OF ADMISSION AND DEATH22

23. DIAGNOSIS OF MORTALITY CASES Immediate Cause of death
Fulfillment of WHO Case Definition
(WHO 1997)
Percentage of Cases DF
DHF 11
DSS 89
CAUSE OF DEATH
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)
Others (specify) Hyperkalemia with ARF
12.7 23

24. 36.4 CONTRIBUTING FACTORS FOR DENGUE MORTALITY N0.% 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
Others
16.4 24

25. CONTRIBUTING FACTORS FOR DENGUE MORTALITY% 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
Delay in seeking ICU care
14.5
Inadequate monitoring of FBC
10.9
DIVC not suspected/recognized
1.8 4.
CO MORBID CONDITIONS
Obesity
Extremes of age (<1yr / >60yrs)
9.1
Others – Uncontrolled DM/HPT; Hepatitis, Fits
53% of the death were preventable 25

26. 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

27. 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

28. 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 28

29. 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 29

30. 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

31. 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

32. THANK YOU FOR YOUR ATTENTION