Status of Status of MALARIA CONTROL MALARIA CONTROL

in Malaysiain Malaysiabyby

DR. MARZUKHI MD. ISADR. MARZUKHI MD. ISADEPUTY DIRECTOR DISEASE CONTROLDEPUTY DIRECTOR DISEASE CONTROL

(Vector Borne Diseases)(Vector Borne Diseases)DISEASE CONTROL DIVISIONDISEASE CONTROL DIVISION

MINISTRY OF HEALTH, MALAYSIAMINISTRY OF HEALTH, MALAYSIA

June 2004June 2004

Scope of PresentationScope of Presentation

•• Current Status of malaria in MalaysiaCurrent Status of malaria in Malaysia•• Areas of ConcernAreas of Concern

–– SarawakSarawak–– SabahSabah–– PahangPahang

•• Drug Resistance StudyDrug Resistance Study•• Future InterventionsFuture Interventions•• ConclusionConclusion

INTERVENTIONAL MILESTONES IN INTERVENTIONAL MILESTONES IN MALARIA CONTROLMALARIA CONTROL20022002Increase Increase bednets bednets coverage and strengthen coverage and strengthen

malaria surveillance in Sarawak, malaria surveillance in Sarawak, Pahang Pahang and and SabahSabah,,

20032003--Intensify case detection and vector control in Intensify case detection and vector control in

Orang Asli Orang Asli areas,areas,--Intensify malaria surveillance in urban areas Intensify malaria surveillance in urban areas

and malaria prone areas,and malaria prone areas,

Malaria Burden in Malaysia 1961Malaria Burden in Malaysia 1961--20032003

1101

963

3887

2

2438

70

1814

9515

1822

8743

244

226

4952

648

007

4170

855

068

6912

754

831

4354

536

853

3989

058

958

5920

851

921

2664

913

491

1110

612

705

1278

0

0

50000

100000

150000

200000

250000

300000

1961

1970

1980

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

YEAR

Cas

es

IMPACT OF INTERVENTIONS IN IMPACT OF INTERVENTIONS IN MALARIA CONTROL FROM 1961 MALARIA CONTROL FROM 1961 –– 20032003

1101

9

6338

872

Est

ablis

hmen

t of i

nter

natio

nal

train

ing

cent

re fo

r Tra

nsfe

r of T

rain

ing

Tech

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ours

e

Pol

icy

chan

ge o

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mic

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sect

icid

e fro

m D

DT

to p

yret

hroi

ds

Impl

emen

tatio

n of

inse

ctic

ide

treat

ed

bedn

ets

for m

alar

ia c

ontro

lIm

plem

enta

tion

of 5

yea

r Act

ion

Pla

n fo

r Mal

aria

Con

trol i

n S

abah

Ado

ptio

n of

Prim

ary

Hea

lth C

are

Appr

oach

in m

alar

ia c

ontro

l

Impl

emen

tatio

n of

DB

IA '7

5 th

roug

hout

Mal

aysi

a

0

50000

100000

150000

200000

250000

300000

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

Cas

es

IR and CFR 1961 IR and CFR 1961 -- 20032003

23.9

19.320.9

30.2

24.5

12.3

6.14.9 5.5 5.3

4.522.8

29.7

0.1

0.060.05

0.040.05

0.07

0.2

0.24

0.35 0.35

0.32

0.19

0.09

0

5

10

15

20

25

30

35

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Inci

denc

e Ra

te p

er 1

0,00

0

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

Case

Fat

ality

Rat

e

I.R C.F.R

Future Intervention (2004)Future Intervention (2004)

•• Improving of bed nets coverage among Improving of bed nets coverage among OrangOrangAsliAsli in Peninsular Malaysia. in Peninsular Malaysia.

•• Improving coverage in the interior of Peninsular Improving coverage in the interior of Peninsular Malaysia Malaysia

•• Improving of Coverage of bed nets in Sarawak Improving of Coverage of bed nets in Sarawak •• Special projects carried under National MMFO in Special projects carried under National MMFO in

20032003--4 projects implemented and 4 projects implemented and continous continous monitoringmonitoring--twice/yeartwice/year

<1 ta

hun

1-4

5-9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

Age Groups

0

10

20

Thou

sand

sY

-Axi

s

0

1,000

2,000

1992199319941995199619971998199920002001200220032004

No. of Malaria cases by Age Group in Malaysia

Malaria Cases by Age Group, 2003Malaria Cases by Age Group, 2003

0100200300400500600

700800

'<1year

5-9year

15-19year

25-29year

35-39year

45-49year

>55years

SarawakSabahPen. Malaysia

CRITERIA FOR MALARIA STRATIFICATIONSCRITERIA FOR MALARIA STRATIFICATIONS

No indigenous cases within 3 yearsNo indigenous cases within 3 yearsAnnual Parasite Incidence (API) less than Annual Parasite Incidence (API) less than 0.1/10000.1/1000Annual Blood Examination Rate (ABER) more Annual Blood Examination Rate (ABER) more than 10%than 10%Absence of malaria vectorsAbsence of malaria vectorsMatured surveillance systemMatured surveillance systemAvailability and accessibility of Health Clinics Availability and accessibility of Health Clinics

MAP OF MALARIA STRATIFIED AREAS IN MALAYSIA 2001

U

PERLISKEDAHP. PINANGPERAKKELANTANTERENGGANUPAHANGSELANGORN. SEMBILANMELAKAJOHOR

ABCDEFGHJKL

CODE STATE

MALARIOUS AREAMALARIA PRONENON MALARIOUS AREAS

> 10/10,000

1 - 10/10,000

< 1/10,000

REFERENCE

2

PULAUTIOMAN

THAILAND

PULAULANGKAWI

PULAUPINANG

E

GH

KL

C

BAU

BARAM

MIRI

BRUNEI

SARAWAK

NAN

TENOM

KENINGAU

SABAH

PAPA

R

RANAUTAMBU

A

B

D

J

F

SINGAPORE

Malarious Area ( >10 Kes/10,000 penduduk)

Malaria Prone ( 1-10 kes/10,000 penduduk)

Malaria Free ( <1 kes/10,000 penduduk)

MALARIA STATIFICATION AREA 2003

Incidence Rate/10,000 by Incidence Rate/10,000 by State, 2003State, 2003

0

2

4

6

8

10

12

Sara

wak

Saba

hP

ahan

g

Per

akJo

hor

WP

Lab

uan

P P

inan

gK

elan

tan

Ked

ahN

Sem

bila

n

Tere

ngga

nuSe

lang

or

WP

KL

Mel

aka

Per

lisM

ALA

YSI

A

Incidence Rate (/10,000)

Malaria cases admitted to hospital 2003Malaria cases admitted to hospital 2003

2615

1770

850276284

7 106 99 45 47 119 20 1 7

6338

0

1000

2000

3000

4000

5000

6000

7000

Sara

wak

Saba

h

Pah

ang

Per

ak

Joho

r

WP

Lab

uan

P P

inan

g

Kel

anta

n

N S

embi

lan

Tere

ngga

nu

Sela

ngor

WP

KL

Per

lis

Mel

aka

MA

LAY

SIA

total no. of cases admitted to hospital

Incidence Rate in Sarawak by Incidence Rate in Sarawak by DistrictDistrict

0

5

10

15

20

25

30

35

Kap

it

Sri A

man

Sam

arah

an

Bin

tulu

Mir

i

Kuc

hin

g

Lim

ban

g

Sib

u

Sari

kei

SAR

AW

AK

Incidence Rate (/10,000)

Incidence Rate in Incidence Rate in Sabah Sabah by Districtby District

0

10

20

30

40

50

60

70

Bel

uran

Lah

ad D

atu

Kun

akP

itas

Kot

a M

arud

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Kin

abat

anga

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udat

Taw

auSe

mpo

rna

Pen

ampa

ng

K K

inab

alu

Pap

arTu

aran

Sand

akan

Kot

a B

elud

SAB

AH

Incidence Rate (/10,000)

Incidence Rate in Incidence Rate in Pahang Pahang by Districtby District

0

5

10

15

20

25

30

35

40

45

Lipi

sJe

rant

ut

Rau

b

Pek

anR

ompi

n

Ber

aK

uan

tan

Mar

anB

ento

ngTe

mer

loh

C H

ighl

ands

PA

HA

NG

Incidence Rate (/10,000)

Incidence Rate in Incidence Rate in Perak Perak by Districtby District

0

2

4

6

8

10

12

14

16

Hul

u Pe

rak

Kin

taB

Pada

ngK

Kan

gsar

Man

jung

Ker

ian

Hili

r Pe

rak

L M

Sel

ama

P Te

ngah

PER

AK

Incidenc Rate (/10,000)

Issues in malaria controlIssues in malaria control•• Geographical inaccessibilityGeographical inaccessibility

–– Delay in diagnosis and treatmentDelay in diagnosis and treatment–– Delay in followDelay in follow--upup–– Increased transmissionIncreased transmission

•• Mobile populationsMobile populations–– Orang AsliOrang Asli, ethnic groups, ethnic groups

•• Immigrants from endemic countriesImmigrants from endemic countries–– ReRe--emergence of malaria in previously free areasemergence of malaria in previously free areas

•• Rapid turnRapid turn--over and retirement of malaria over and retirement of malaria workersworkers–– Loss of skill, knowledgeLoss of skill, knowledge

Strategies in malaria controlStrategies in malaria control•• Extended detection and treatment of malaria in Extended detection and treatment of malaria in

remote areas in remote areas in SabahSabah–– Subsector Subsector officesoffices

•• Integration of control operationsIntegration of control operations–– Border states of Malaria Triangle in Border states of Malaria Triangle in Orang Asli Orang Asli areasareas

•• Active surveillance of foreign workers and outbreak Active surveillance of foreign workers and outbreak controlcontrol

•• Vector controlVector control–– IRS and ITNIRS and ITN

•• Community involvementCommunity involvement•• Capacity buildingCapacity building

–– MMFO, microscopyMMFO, microscopy

•• Area Area prioritisationprioritisation–– Sarawak,Sarawak, SabahSabah,, PahangPahang

National AntiNational Anti--malarial Drug Response malarial Drug Response Surveillance Surveillance ProgrammeProgramme

•• Started from January 2003Started from January 2003•• RationaleRationale

–– First line antiFirst line anti--asexual have been used since 1960asexual have been used since 1960’’s (CHL) s (CHL) and since late 1970and since late 1970’’s (SP)s (SP)

–– Effective first line antiEffective first line anti--malarialsmalarials are important for clinical are important for clinical cure (prevention of complication and death) and effective cure (prevention of complication and death) and effective control (source reduction)control (source reduction)

–– To gather representative data from the whole country to To gather representative data from the whole country to monitor the situation of resistance and to confirm the monitor the situation of resistance and to confirm the expected trend of increasing drug resistance.expected trend of increasing drug resistance.

18 18 sentinel sites sentinel sites in 7 endemic statesin 7 endemic states

StateState No. of sitesNo. of sites SitesSites

KedahKedah 22 KulimKulim, Baling, Baling

KelantanKelantan 11 Gua MusangGua Musang

PahangPahang 44 RaubRaub, , LipisLipis, , JerantutJerantut, , MuadzamMuadzam

PerakPerak 22 TapahTapah, , GerikGerik

TerengganuTerengganu 11 KemamanKemaman

SarawakSarawak 22 Sri Sri AmanAman, , SerianSerian, , LunduLundu

SabahSabah 44 TelupidTelupid, Kota , Kota MaruduMarudu, , BanggiBanggi, Pitas, Pitas

Criteria for inclusionCriteria for inclusion•• Asexual Asexual P. P. falciparum falciparum monomono--infectioninfection•• NonNon--severesevere

–– (severe defined as (severe defined as •• Requiring quinine treatmentRequiring quinine treatment•• Requiring referral)Requiring referral)

•• Started on first line drugs:Started on first line drugs:–– CHL (+ PRI) : SarawakCHL (+ PRI) : Sarawak–– SP (+ PRI) : SP (+ PRI) : SabahSabah–– CHL + SP (+ PRI) : Peninsular MalaysiaCHL + SP (+ PRI) : Peninsular Malaysia

Sentinel sites to submit, Sentinel sites to submit, on monthly basis:on monthly basis:

•• The report on:The report on:--Cases completing 28Cases completing 28--day follow upday follow up–– Failure of follow up to D28Failure of follow up to D28–– Conversion to 2Conversion to 2ndnd line drugs treatment or line drugs treatment or

referralreferral

DefinitionDefinition

ValidValid Recruited patient conforms to inclusion / exclusion Recruited patient conforms to inclusion / exclusion criteriacriteria

InIn--validvalid Recruited patient not conforming to criteria / not Recruited patient not conforming to criteria / not given appropriate drugs and dosagegiven appropriate drugs and dosage

SensitiveSensitive Adequate drug response ( Complete clearance of Adequate drug response ( Complete clearance of asexual stages until D28)asexual stages until D28)

ResistantResistant Persistent or reappearance of asexual Persistent or reappearance of asexual parasitemia parasitemia before D28, or referred, or changed to quinine before D28, or referred, or changed to quinine treatment, or clinical deteriorationtreatment, or clinical deterioration

Early treatment Early treatment failurefailure

Persistent or reappearance of asexual Persistent or reappearance of asexual parasitemia parasitemia before D7before D7

Late treatment Late treatment failurefailure

Persistent or reappearance of asexual Persistent or reappearance of asexual parasitemia parasitemia after D7after D7

InconclusiveInconclusive Valid cases recruited, responding to initial treatment, Valid cases recruited, responding to initial treatment, but lost to follow upbut lost to follow up

Summary of response by drugs at D28Summary of response by drugs at D28

DrugDrug Valid Valid casescases

ComCom--pletedpletedD28D28

IncomIncom--plete plete (%)(%)

AdeqAdeq. . ResponsResponse (%)e (%)

Early Early failure failure (%)(%)

Late Late failure failure (%)(%)

Total Total failure failure (%)(%)

CHLCHL 9393 7373 20 (20.4)20 (20.4) 40 (54.8)40 (54.8) 18 (24.7)18 (24.7) 1515(20.5)(20.5)

32 (45.2)32 (45.2)

SPSP 5252 1212 40 (76.9)40 (76.9) 10 (83.3)10 (83.3) 1 (8.3)1 (8.3) 1 (8.3)1 (8.3) 2 (16.7)2 (16.7)

CHL + CHL + SPSP

164164 112112 52 (31.7)52 (31.7) 77 (68.8)77 (68.8) 16 (14.3)16 (14.3) 19 (17.0)19 (17.0) 35 (31.3)35 (31.3)

TotalTotal 309309 197197 112 112 (36.2)(36.2)

127 127 (64.5)(64.5)

35 (17.8)35 (17.8) 35 (17.8)35 (17.8) 70 (35.5)70 (35.5)

Future Interventions (2004)Future Interventions (2004)•• Improving of bed nets coverage among Improving of bed nets coverage among OrangOrang AsliAsli in in

Peninsular Malaysia. Peninsular Malaysia. •• Improving coverage in the interior of Peninsular Malaysia Improving coverage in the interior of Peninsular Malaysia •• Drug Policy ChangeDrug Policy Change•• Improving of Coverage of bed nets in Sarawak Improving of Coverage of bed nets in Sarawak •• Special projects carried under National MMFO in 2003Special projects carried under National MMFO in 2003--4 4

projects implemented and projects implemented and continous continous monitoringmonitoring--twice/yeartwice/year•• Online surveillance of malaria activitiesOnline surveillance of malaria activities•• Increase professional capacity and surveillance capability in Increase professional capacity and surveillance capability in

malaria controlmalaria control2004/2005 2004/2005 --33rdrd National MMFONational MMFO

Future Intervention (2004)Future Intervention (2004)

•• Improving of bed nets coverage among Improving of bed nets coverage among OrangOrangAsliAsli in Peninsular Malaysia. in Peninsular Malaysia.

•• Improving coverage in the interior of Peninsular Improving coverage in the interior of Peninsular Malaysia Malaysia

•• Improving of Coverage of bed nets in Sarawak Improving of Coverage of bed nets in Sarawak •• Special projects carried under National MMFO in Special projects carried under National MMFO in

20032003--4 projects implemented and 4 projects implemented and continous continous monitoringmonitoring--twice/yeartwice/year

1995*1996*

1997*1998*

1999*2000*

2001*2002*

2003* 2004*

2005*2007*

2008*2009*

2010*2011

20122013

20142015

20162017

20182019

X-Axis

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

Est

imat

ed T

arge

t

0

50

100

150

200

Thou

sand

s

Incident rate/10,000

BEDNETS

Projected Target for Malaria Control in Malaysia, 2003-2020