DENGUE EPIDEMIOLOGY
AND CONTROL PROGRAM
IN MALAYSIA
DR ROSE NANI MUDIN
DISEASE CONTROL DIVISION
MINISTRY OF HEALTH
13 JAN 2009
1
OUTLINES OF PRESENTATION




Epidemiology of Dengue in Malaysia
Dengue Mortality
Control Activities Strategies
Conclusion
INCIDENCE RATE OF REPORTED DENGUE CASES
IN MALAYSIA (1981 - 2008)
200
180
180
150.6 148.3
140
123.4
178
132.5
133.5
120
125.9
100
89.7
80
67.3
72
60
44.7
40
27.5 29.5 29.5
15 36.4
20.7
8.8
4.5
5.3
8.5
31.6
32.8
16.1
Y E AR
07
20
05
20
03
20
01
20
99
19
97
19
95
19
93
19
91
19
89
87
19
85
2.4
19
19
83
4.5
81
0
12.4
19
20
19
IR / 100,000 Population
160
3
32422
33895
30220
32767
30807
49335
46518
2817
665
1916
1473
1325
1960
922
2990
13967
13302
16368
15446
7103
6692
411
544
787
532
5000
387
10000
1141
15000
10146
9602
14255
13723
20000
19429
25000
18642
30000
26240
27381
35000
6543
6156
NO. OF CASES
40000
31545
45000
37080
39654
50000
45856
48846
NUMBER OF REPORTED DENGUE FEVER AND
DENGUE HAEMORRHAGIC FEVER CASES IN
MALAYSIA, 1995 – 2007
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Total
DF
DHF
Y E A R
4
DISTRIBUTION OF REPORTED DENGUE CASES IN
MALAYSIA BY EPIDEMIOLOGY WEEK (2006–2008)
1800
1600
1400
NO. OF CASES
1200
1000
800
600
400
200
0
1
3
5
7
Epid.
9 11
13 Week
15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
EPID
Median 03-07 MINGGU
2007
2008
2006
5
COMPARISION OF DENGUE CASES BY STATE
(2007 & 2008)
25000
NO. OF CASES
21262
20000
15891
15000
10000
7439
5446
4219
5000
2584
1678
311
3908
2889
3106
2324
1405
3363
830
1275
184
732
2657
1327
1721
1269
1953
3503
2399
1045
70
1845
1517
29
2007
2008
RA
W
AK
SA
UA
N
LA
B
SA
BA
H
JO
HO
R
PA
HA
TE
NG
RE
NG
GA
NU
KE
LA
NT
AN
A
EL
AK
M
BI
LA
N
L
N.
SE
M
W
PK
PE
RA
K
SE
LA
NG
OR
PI
NA
NG
P.
PE
RL
IS
KE
DA
H
0
6
6
THE DENGUE INCIDENCE RATE BY STATE (2008)
78
86
80
150
LABUAN
150
179
157
62
88
408
WPKL
334
33
141
110
118
MALAYSIA
178 cases/100,000population
7
PATTERN
OF
DENGUE CASES
RATIO OF DHF : DF IN MALAYSIA
1998 – 2008
16.3
17.3
16.7
19.9
19.8
25
19.4
15.7
17.4
20
15
10
1
1
1
1
1
1
1
1
1
1
1
5
0
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
YE A R
DHF
DF
9
DHF : DF RATIO
22.0
22.8
22.9
PERCENTAGE DISTRIBUTION OF DENGUE CASES
BY LOCALITY IN MALAYSIA (1998 – 2008)
90
77.2
73.6
77.3
83.9
87.1
84.2 83.5
77.3
80
74.2
70.9
70
60
25.8
15.8
12.9
16.1
16.4
20
16.5
26.4
22.8
30
22.7
40
29.1
50
22.6
PERCENTAGE OF CASES
83.6
10
0
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
YEA R
Urban
Rural
10
Circulating Dengue Virus Serotype : 1992-2008
%
100
90
80
70
60
50
40
30
20
10
0
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
DEN 1
11.9
3.7
0
4.8
14.7
48.7
63.5
44.4
28.2
9.3
5.4
29.8
46.9
73.4
58.6
33
30
33
DEN 2
54.2
8.6
4.1
9.5
29.5
48.7
33.4
51.9
69.2
58.1
39.2
23.8
20.6
7.4
8.4
36.4
53
40
DEN 3
32.5
83.7
93.1
84.1
54.6
2.6
2.1
3.7
2.7
32.6
50
33.3
27.8
14.6
17.1
19.3
11
16
DEN 4
1.4
4
2.8
1.6
1.2
0
0
0
0
0
5.4
13.1
4.7
4.6
1.2
4.5
6
11
DEN 1
DEN 2
DEN 3
DEN 4
11
11
DHF AND DF FATALITY RATES FOR
MALAYSIA (1990-2008)
12
10.2
7.31
8
6.8
6.23
6
4.9
5.08
5.27
4
6.4
6.02
3.72
5.6
5.1
5.3
4.14
3.9
3.26
3.1
2
0.58 0.44
0
3.8
5.1
0.43
0.41
0.41 0.43 0.22 0.26 0.29 0.36 0.63 0.31 0.3
0.23
0.3
0.27
0.23 0.2
0.01
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
Fatality Rate
10
DHF
DF
Year
12
DISTRIBUTION OF DENGUE DEATH CASES
BY AGE GROUP (1997 – 2007)
NO. OF CASES
90
80
70
60
50
40
30
20
10
0
1997
1998
1999
2000
2001
0-14YEARS
2002
2003
2004
2005
>15 YEARS
2006
2007
YEAR
13
FINDINGS
OF
DENGUE CASES ANALYSIS
FOR 2008
14
DISTRIBUTION OF DENGUE CASES BY GENDER
15
DISTIRBUTION OF DENGUE CASES BY AGE GROUP
16
FINDINGS OF VEKPRO ANALYSIS FOR 2008 (Epid wk 1- 49)
% 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 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
17
MALAYSIA
74.2
85.4
3.4
34.5
18.8
State
DENGUE MORTALITY ANALYSIS
2008
18
DENGUE MORTALITY

112 dengue deaths reported for 2008 (98
cases in 2007

Only 62 cases were reviewed by the state
mortality review committee
19
DISTRIBUTION OF DENGUE MORTALITY
BY AGEGROUP
25
Percent (%)
20
15
23.6%
21.8%
10
14.5%
12.7%
5
7.3%
7.3%
7.3%
5.5%
0
<1
1-10
11-20
21-30
31-40
Agegroup (years)
41-50
51-60
>=61
20
DURATION BETWEEN TIME OF ONSET AND ADMISSION
21
DURATION BETWEEN TIME OF ADMISSION
AND DEATH
22
DIAGNOSIS OF MORTALITY CASES
Fulfillment of WHO Case Definition
(WHO 1997)
Percentage of
Cases
DF
0
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)
10.9
Others (specify) Hyperkalemia with ARF
12.7
23
CONTRIBUTING FACTORS FOR DENGUE MORTALITY
N0. CONTRIBUTING FACTORS
1. PATIENT CAME IN ALREADY TOO ILL
2. DELAY IN DIAGNOSIS/ ASSESSMENT
OF SEVERITY
Low index of suspicion
%
47.3
36.4
Delay in review by doctor
14.5
Late referral
9.1
7.3
Results delayed/not traced/not
reviewed
Infrequent investigation ordered
Others
7.3
16.4
24
CONTRIBUTING FACTORS FOR DENGUE MORTALITY
N0.
3.
4.
CONTRIBUTING FACTORS
%
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
CO MORBID CONDITIONS
Obesity
14.5
Extremes of age (<1yr / >60yrs)
9.1
Others – Uncontrolled DM/HPT; Hepatitis, Fits
18.2
53% of the death were preventable
25
Key Components of Dengue Control Strategy

Early diagnosis and treatment




Prompt notification





Training of frontliners
Health education to public on importance of early diagnosis
and treatment
Active case detection in outbreak localities
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
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
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
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
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
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
THANK YOU
FOR YOUR
ATTENTION
32