DENGUE EPIDEMIOLOGY AND CONTROL PROGRAMIN MALAYSIADR ROSE NANI MUDINDISEASE CONTROL DIVISIONMINISTRY OF HEALTH13 JAN 2009*

OUTLINES OF PRESENTATIONEpidemiology of Dengue in MalaysiaDengue Mortality Control Activities StrategiesConclusion

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

NUMBER OF REPORTED DENGUE FEVER AND DENGUE HAEMORRHAGIC FEVER CASES IN MALAYSIA, 1995 2007 *

*DISTRIBUTION OF REPORTED DENGUE CASES IN MALAYSIA BY EPIDEMIOLOGY WEEK (20062008)Epid. Week

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Median 03-07

2007

2008

2006

MINGGU EPID

NO. OF CASES

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1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950515253

Median 03-0710941482113713541081984937808718699662643566476467451455467567642669598599686717721777739811687673717731765656753686783661781709726829760743799859884858861723732732

2007120915431475135412311223103380887788479077781371079280675972793310571003105099310021145109711301045112311531004982941910784911816852797915803726862821743847859884858861723732

20087337918418428146508888498147046525756487566667768648659491082995104593291691198310341008980106910341071103910031014850832915964702100796187592596810711121106612731155126012691157

2006549664693693562720699743718699662643608593567542564502567761755671636766753757777884927929902789817765656753666673657674709708403824880890878907955103111901225

*COMPARISION OF DENGUE CASES BY STATE (2007 & 2008)*NO. OF CASES20072008

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PERLIS311184

KEDAH25841678

P. PINANG31062324

PERAK28894219

SELANGOR1589121262

WPKL74395446

N.SEMBILAN12751405

MELAKA732830

JOHOR33633908

PAHANG26571327

TERENGGANU12691721

KELANTAN35032399

SABAH19531045

LABUAN2970

SARAWAK18451517

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311184

25841678

31062324

28894219

1589121262

74395446

12751405

732830

33633908

26571327

12691721

35032399

19531045

2970

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PERLISKEDAHPULAU PINANGPERAKSELANGORW.PERSEKUTUANN.SEMBILANMELAKAJOHORPAHANGTERENGGANUKELANTANSABAHWP LABUANSARAWAK

2007

2008

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THE DENGUE INCIDENCE RATE BY STATE (2008)334MALAYSIA 178 cases/100,000populationWPKL150788617914111011888157

150

3362*LABUAN80408

PATTERN OF DENGUE CASES

*RATIO OF DHF : DF IN MALAYSIA 1998 2008DHF : DF RATIO

*PERCENTAGE DISTRIBUTION OF DENGUE CASES BY LOCALITY IN MALAYSIA (1998 2008)

**%

EMBED MSGraph.Chart.8 \s

Circulating Dengue Virus Serotype : 1992-2008

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

DISTRIBUTION OF DENGUE DEATH CASES BY AGE GROUP (1997 2007) NO. OF CASESYEAR*

*FINDINGS OF DENGUE CASES ANALYSISFOR 2008

*DISTRIBUTION OF DENGUE CASES BY GENDER

*DISTIRBUTION OF DENGUE CASES BY AGE GROUP

*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 < 5 d from OnsetPerlis81.863.08.537.439.2Kedah65.955.21.146.531.5P. Pinang33.075.71.150.436.5Perak64.097.51.338.930.1Selangor95.891.75.731.713.5WPKL8.084.70.934.47.8N. Sembilan78.099.10.630.921.9Melaka65.799.50.235.929.9Johor93.784.30.232.719.6Pahang85.584.51.434.124.3Terengganu81.151.51.336.935.6Kelantan88.175.43.628.117.8Sabah45.579.13.335.218.2WP Labuan28.635.6062.955.7Putrajaya56.8100.014.525.57.8Sarawak37.190.310.942.018.2MALAYSIA74.285.43.434.518.8

*DENGUE MORTALITY ANALYSIS2008

*DENGUE MORTALITY112 dengue deaths reported for 2008 (98 cases in 2007

Only 62 cases were reviewed by the state mortality review committee

*DISTRIBUTION OF DENGUE MORTALITY BY AGEGROUP

*DURATION BETWEEN TIME OF ONSET AND ADMISSION

*DURATION BETWEEN TIME OF ADMISSION AND DEATH

*CAUSE OF DEATHDIAGNOSIS OF MORTALITY CASES

Immediate Cause of deathPercentage of Cases Shock Syndrome61.8End/Multi organ failure40.0Severe bleeding from GIT/DIVC/Thrombocytopenia32.7ARDS10.9Sepsis (including Nosocomial infection)10.9Others (specify) Hyperkalemia with ARF12.7

Fulfillment of WHO Case Definition (WHO 1997) Percentage of CasesDF0DHF11DSS89

*CONTRIBUTING FACTORS FOR DENGUE MORTALITY

N0.CONTRIBUTING FACTORS %1.PATIENT CAME IN ALREADY TOO ILL47.32.DELAY IN DIAGNOSIS/ ASSESSMENT OF SEVERITYLow index of suspicion36.4Delay in review by doctor14.5Late referral9.1Results delayed/not traced/not reviewed7.3Infrequent investigation ordered7.3Others16.4

*53% of the death were preventableCONTRIBUTING FACTORS FOR DENGUE MORTALITY

N0.CONTRIBUTING FACTORS%3.INADEQUATE MONITORING/TREATMENTInadequate fluid resuscitation21.8Failure to recognize DSS20.0Insufficient blood products given18.2Inadequate monitoring of vital signs16.4Overloading/pulmonary oedema16.4Delay in seeking ICU care14.5Inadequate monitoring of FBC10.9DIVC not suspected/recognized1.84.CO MORBID CONDITIONSObesity14.5Extremes of age (60yrs)9.1Others Uncontrolled DM/HPT; Hepatitis, Fits18.2

Key Components of Dengue Control Strategy Early diagnosis and treatmentTraining of frontlinersHealth education to public on importance of early diagnosis and treatmentActive case detection in outbreak localitiesPrompt notificationWithin 24 hours By phoneNearest District Health OfficeCase Investigation within 24 hours Prompt vector control responseWithin 24 hours of notificationFogging within 200 m radius400 m if outbreak localityQuality Assurance Program -Dengue Outbreak Control Index (DOCI): 100% outbreak controlled within 14 days

Key Components of Dengue Control Strategy Proper Case ManagementCPG- 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 weeksHealth Education And Community MobilizationProduction of health materials/ mass mediaGuidelines on health education and community mobilization activities in outbreak localitiesGuidelines on COMBI For Dengue Prevention and Control

*CHALLENGES IN THE DENGUE PREVENTION ACTIVITIESHealth seeking behavior of the dengue patient:Only 4% of cases were from the clinic and majority from hospital50% 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 illnessOnly 19% of dengue cases residence were fogged within 5 days of onset of illnessThus other patients infected with the dengue virus may still transmit the disease

*CHALLENGES IN THE DENGUE PREVENTION ACTIVITIESLow index of suspicion of dengue cases by the attending doctors:Delayed notificationDelay in giving appropriate treatment

Lack in community cooperation and participation in the dengue prevention and control activities

CONCLUSION-1To 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 & supervisionAnalysis of data at district, state, and MOH level

CONCLUSION-2Strengthen 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

THANK YOU FOR YOUR ATTENTION*

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