Status of MALARIA CONTROL in Malaysia

Status of MALARIA CONTROL in Malaysia by DR. MARZUKHI MD. ISA DEPUTY DIRECTOR DISEASE CONTROL (Vector Borne Diseases) DISEASE CONTROL DIVISION MINISTRY OF HEALTH, MALAYSIA June 2004

Scope of Presentation Current Status of malaria in Malaysia Areas of Concern Sarawak Sabah Pahang Drug Resistance Study Future Interventions Conclusion

INTERVENTIONAL MILESTONES IN MALARIA CONTROL 2002 Increase bednets coverage and strengthen malaria surveillance in Sarawak, Pahang and Sabah, 2003 -Intensify case detection and vector control in Orang Asli areas, -Intensify malaria surveillance in urban areas and malaria prone areas,

Malaria Burden in Malaysia 1961-2003 300000 872 11019 6338 44226 49526 48007 41708 55068 87432 69127 54831 43545 36853 39890 26649 13491 11106 12705 12780 58958 59208 51921 181495 151822 243870 250000 200000 150000 100000 50000 0 1961 1970 1980 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 YEAR Cases

IMPACT OF INTERVENTIONS IN MALARIA CONTROL FROM 1961 2003 300000 Establishment of international training centre for Transfer of Training Technology Course 11019 6338 872 Implementation of DBIA '75 throughout Malaysia Adoption of Primary Health Care Approach in malaria control Implementation of insecticide treated bednets for malaria control Implementation of 5 year Action Plan for Malaria Control in Sabah 250000 Policy change of chemical insecticide from DDT to pyrethroids 200000 150000 100000 50000 0 Cases 1961 1965 1970 1975 1980 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

IR and CFR 1961-2003 35 0.4 30 25 23.9 30.2 29.7 24.5 0.35 0.35 0.32 0.35 0.3 Incidence Rate per 10,000 20 15 19.3 20.9 12.3 0.2 0.19 0.24 0.25 0.2 0.15 Case Fatality Rate 10 0.1 0.1 5 0.06 0.05 0.04 0.05 0.07 0.09 6.1 4.9 5.5 5.3 4.52 2.8 0.05 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 0 I.R C.F.R

Y-Axis Thousands Future Intervention (2004) Improving of bed nets coverage among Orang Asli in Peninsular Malaysia. 20Improving coverage in the interior of Peninsular 0 10Malaysia 0 Improving of Coverage of bed nets in Sarawak Special projects carried under National MMFO in 2003-4 4 projects implemented and continous monitoring-twice/year twice/year <1 tahun 1-4 No. of Malaria cases by Age Group in Malaysia 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 Age Groups 45-49 50-54 55-59 2,000 1,000 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Malaria Cases by Age Group, 2003 800 700 600 500 Sarawak Sabah Pen. Malaysia 400 300 200 100 0 '< 1year 5-9 year 15-19 year 25-29 year 35-39 year 45-49 year >55 years

CRITERIA FOR MALARIA STRATIFICATIONS No indigenous cases within 3 years Annual Parasite Incidence (API) less than 0.1/1000 Annual Blood Examination Rate (ABER) more than 10% Absence of malaria vectors Matured surveillance system Availability and accessibility of Health Clinics

MAP OF MALARIA STRATIFIED AREAS IN MALAYSIA 2001 A THAILAND U 2 PULAU LANGKAWI B E BRUNEI RANAU TAMBU NAN NGAU KENI PAPAR SABAH TENOM PULAU PINANG C D F SARAWAK MIRI BARAM BAU CODE A B C D E F G H J K L STATE PERLIS KEDAH P. PINANG PERAK KELANTAN TERENGGANU PAHANG SELANGOR N. SEMBILAN MELAKA JOHOR H J K G L PULAU TIOMAN REFERENCE MALARIOUS AREA > 10/10,000 MALARIA PRONE 1-10/10,000 NON MALARIOUS AREAS < 1/10,000 SINGAPORE

MALARIA STATIFICATION AREA 2003 Malarious Area ( >10 Kes/10,000 penduduk) Malaria Prone ( 1-10 kes/10,000 penduduk) Malaria Free ( <1 kes/10,000 penduduk)

Incidence Rate/10,000 by Incidence Rate/10,000 by State, 2003 12 10 8 6 4 2 0 MALAYSIA Sarawak Sabah Pahang Perak Johor WP Labuan P Pinang Kelantan Kedah N Sembilan Terengganu Selangor WP KL Melaka Perlis Incidence Rate (/10,000)

Malaria cases admitted to hospital 2003 Malaria cases admitted to hospital 2003 7000 6000 6338 5000 4000 3000 2000 2615 1770 1000 0 850 276284 7 106 99 45 47 119 20 1 7 Sarawak Sabah Pahang Perak Johor WP Labuan P Pinang Kelantan N Sembilan Terengganu Selangor WP KL Perlis Melaka MALAYSIA total no. of cases admitted to hospital

Incidence Rate in Sarawak by Incidence Rate in Sarawak by District 35 30 25 20 15 10 5 Kapit Sri Aman Samarahan Bintulu Miri Kuching Limbang Sibu Sarikei SARAWAK 0 Incidence Rate (/10,000)

Incidence Rate in Sabah by District 70 60 50 40 30 20 10 0 Beluran Lahad Datu Kunak Pitas Kota Marudu Ranau Kinabatangan Kudat Tawau Semporna Penampang K Kinabalu Papar Tuaran Sandakan Kota Belud SABAH Incidence Rate (/10,000)

Incidence Rate in Pahang by District 45 40 35 30 25 20 15 10 5 Lipis Jerantut Raub Pekan Rompin Bera Kuantan Maran Bentong 0 Temerloh C Highlands PAHANG Incidence Rate (/10,000)

Incidence Rate in Perak by District 16 14 12 10 8 6 4 2 0 Hulu Perak Kinta B Padang K Kangsar Manjung Kerian Hilir Perak L M Selama P Tengah PERAK Incidenc Rate (/10,000)

Issues in malaria control Geographical inaccessibility Delay in diagnosis and treatment Delay in follow-up Increased transmission Mobile populations Orang Asli,, ethnic groups Immigrants from endemic countries Re-emergence emergence of malaria in previously free areas Rapid turn-over and retirement of malaria workers Loss of skill, knowledge

Strategies in malaria control Extended detection and treatment of malaria in remote areas in Sabah Subsector offices Integration of control operations Border states of Malaria Triangle in Orang Asli areas Active surveillance of foreign workers and outbreak control Vector control IRS and ITN Community involvement Capacity building MMFO, microscopy Area prioritisation

National Anti-malarial Drug Response Surveillance Programme Started from January 2003 Rationale First line anti-asexual asexual have been used since 1960 s s (CHL) and since late 1970 s s (SP) Effective first line anti-malarials are important for clinical cure (prevention of complication and death) and effective control (source reduction) To gather representative data from the whole country to monitor the situation of resistance and to confirm the expected trend of increasing drug resistance.

18 sentinel sites in 7 endemic states State No. of sites Sites Kedah 2 Kulim,, Baling Kelantan 1 Gua Musang Pahang 4 Raub Raub, Lipis, Jerantut, Muadzam Perak 2 Tapah, Gerik Terengganu 1 Kemaman Sarawak 2 Sri Aman, Serian, Lundu Sabah 4 Telupid Telupid,, Kota Marudu, Banggi,, Pitas

Criteria for inclusion Asexual P. falciparum mono-infection Non-severe (severe defined as Requiring quinine treatment Requiring referral) Started on first line drugs: CHL (+ PRI) : Sarawak SP (+ PRI) : Sabah CHL + SP (+ PRI) : Peninsular Malaysia

Sentinel sites to submit, on monthly basis: The report on: -Cases completing 28-day follow up Failure of follow up to D28 Conversion to 2 nd line drugs treatment or referral

Definition Valid In-valid Sensitive Resistant Early treatment failure Late treatment failure Inconclusive Recruited patient conforms to inclusion / exclusion criteria Recruited patient not conforming to criteria / not given appropriate drugs and dosage Adequate drug response ( Complete clearance of asexual stages until D28) Persistent or reappearance of asexual parasitemia before D28, or referred, or changed to quinine treatment, or clinical deterioration Persistent or reappearance of asexual parasitemia before D7 Persistent or reappearance of asexual parasitemia after D7 Valid cases recruited, responding to initial treatment, but lost to follow up

Summary of response by drugs at D28 Drug Valid cases Com- pleted D28 Incom- plete (%) Adeq. Respons e (%) Early failure (%) Late failure (%) Total failure (%) CHL 93 73 20 (20.4) 40 (54.8) 18 (24.7) 15 (20.5) 32 (45.2) SP 52 12 40 (76.9) 10 (83.3) 1 (8.3) 1 (8.3) 2 (16.7) CHL + SP 164 112 52 (31.7) 77 (68.8) 16 (14.3) 19 (17.0) 35 (31.3) Total 309 197 112 (36.2) 127 (64.5) 35 (17.8) 35 (17.8) 70 (35.5)

Future Interventions (2004) Improving of bed nets coverage among Orang Asli in Peninsular Malaysia. Improving coverage in the interior of Peninsular Malaysia Drug Policy Change Improving of Coverage of bed nets in Sarawak Special projects carried under National MMFO in 2003-4 projects implemented and continous monitoring-twice/year twice/year Online surveillance of malaria activities Increase professional capacity and surveillance capability in malaria control 2004/2005-3 rd National MMFO

Projected Target for Malaria Control in Malaysia, 2003-2020 35.00 Future Intervention (2004) 200 Estimated Target 30.00 25.00 20.00 15.00 10.00 Improving of bed nets coverage among Orang Asli in Peninsular Malaysia. BEDNETS Improving coverage in the interior of Peninsular Malaysia Improving of Coverage of bed nets in Sarawak Special projects carried under National MMFO in 2003-4 4 projects implemented and continous monitoring-twice/year twice/year 5.00 0.00 Incident rate/10,000 1995* 1997* 1999* 2001* 2003* 2005* 2008* 2010* 2012 2014 2016 2018 1996* 1998* 2000* 2002* 2004* 2007* 2009* 2011 2013 2015 2017 2019 X-Axis 150 100 50 0 Thousands