DR. ZUHAIDA BINTI A. JALILKETUA PENOLONG PENAGARAH KANAN

SEKTOR SURVELAN PENYAKIT, BKP1 APRIL 2018

MOH Malaysia: The Organizational Structure For Surveillance

• National Level:

– Disease Control Division

– Responsible for legislation, policy, norms and standards for surveillance

• State Level: The State Health Department

• District Level: The District Health Office

Surveillance Systems in Malaysia

The Components of PH Surveillance

Systematic data framework

development

Data collection

Data analysis & interpretation

Timely information dissemination

Evaluation of public health actions

The Operational Framework:Surveillance, Risk Assessment & Response

EBS IBS

THE ESTABLISHMENT OF PUBLIC HEALTH SURVEILLANCE IN MALAYSIA

Nipah Virus Outbreak

• Among pig-handlers

• September 1998 – May 1999

• Outcome:

– 265 cases of acute encephalitis with 105 deaths

– Mortality rate ≈ 40%

– 1.1 million pigs culled

– Direct economic impact (Loss of ≈ USD625 million)

• Causative agent: A novel paramyxovirus i.e. Nipah virus

▪ 1999: Inter Ministry Committee on the Control of Zoonotic Diseases

▪ 2001: Infectious Disease Surveillance Section, Disease Control Division

▪ 2002: Epidemic Intelligence Programme (EIP) Malaysia

Way Forward

• Preparedness – capacities and capabilities

• Rapid response

• Proper management of the livestock industry

• Early & accurate surveillance crucial

• Early identification of pathogen would have resulted in earlier control of outbreak

• Multi-sectoral cooperation

Lesson Learnt

Malaysia: Indicator-Based Surveillance

• Mandatory Notification– Prevention and Control of Infectious Diseases Act 1988 (Act 342)

– 28 notifiable infectious diseases

– Health facility based reporting

– Notify within 24 hours (9 diseases: cholera, dengue fever, diphtheria, ebola-marburg disease, food poisoning, plague, poliomyelitis, rabies, yellow fever)

• Laboratory-Based Surveillance– Introduced in year 2005– Coordinated by the National Public Health Laboratory (NPHL) Sg. Buloh– Pathogens prioritised: S. Typhi, S. Paratyphi, Salmonella spp.,

N. Meningitidis, H. Influenza Type B and V. Cholerae

• Sentinel Surveillance – e.g. Influenza-like Illness; ILI and Severe Acute Respiratory Infection; sARI

Case Definitions –Infectious Diseases

• Clinically Compatible Case –compatible syndrome

• Suspected Case

– common clinical presentation

• Probable Case

– epidemiological link

• Confirmed Case

– laboratory result

What is a case definition?(time, place & person)

Laboratory-Based Surveillance

• Objectives:

❖ To detect emerging pathogen strain.

❖ To predict and detect outbreak of disease.

❖ To determine and monitor the circulation of organism strains in the country.

❖ To monitor the trend of anti-microbial resistance.

❖ To facilitate outbreak identification and investigation through strain identification (serotyping, phage typing etc.)

Pathogens Identified For National Laboratory Surveillance

Sentinel Surveillance

• Dengue

• Influenza

• Enterovirus

Viral National Surveillance

• Japenese encephalitis

• Mumps, Measles and Rubella

12

Non Viral Pathogens

▪ H. influenzae type B

▪ Neisseriae meningitides

▪ Salmonella typhi

▪ Salmonella paratyphi

▪ Salmonella spp.

▪ Vibrio cholerae

Sentinel Surveillance:Malaysia Influenza Surveillance Programme

• Sentinel surveillance involves systematically collecting data on a routine basis from a limited number of surveillance sites

• Started in January 2016

• 2 major components:– Disease-based surveillance:

▪ 14 sentinel health clinics - for ILI surveillance

▪ 9 sentinel hospitals – for SARI Surveillance

– Laboratory-based surveillance:

▪ 1 National Influenza Centres (NIC) & 1 National Influenza Lab (NIL)

▪ sentinel sites per state for clinical specimen collection

▪ 5 specimens from ILI / SARI cases per clinic per week should be collected

Flow of Data/Information Related To Influenza Surveillance

Sentinel Sites: ILI / SARI Cases• Make a diagnosis• Treat accordingly • Referral to hospital (if necessary)• Recorded in return form

DISTRICT

STATE

Surveillance Section,Ministry of Health Malaysia

Send clinical specimens for viral isolation to NPHL Sungai Buloh

(NIL)•5 specimens /week

Inst. Med. Research (NIC)

SYNDROMIC SURVEILLANCE

• Case definition based on a syndrome, not on a specific disease

• Rely on immediate reporting of event to the system → rapid risk assessment and immediate response

• Designed to detect rare yet high-impact outbreaks

• Type of specimens to be collected will depend on the syndrome encountered

• Health facility based reporting

Syndromic Surveillance:The Objectives

• To facilitate & expedite notification & response using clinical syndromes to define & capture all diseases that potentially cause outbreaks

• To alert attention to a problem at the earliest possible time and to promote rapid investigation & containment of the outbreak

• To complement other existing specific disease notification & is especially useful for rapid response to newly emerging and reemerging diseases & the deliberate release of biological agents

THE SYNDROMES

1) Acute neurological syndrome

2) Acute respiratory syndrome

3) Acute dermatological syndrome

4) Acute haemorrhagic syndrome

5) Acute jaundice syndrome

6) Acute diarrhoeal syndrome

Syndromic Surveillance:The Common Features

• ACUTE: Defined as a period of 3 weeks or less

• SEVERE ILLNESS: Characterized by at least one of the following:• hospital admission

• major organ failure

• altered stated of consciousness

• circulatory collapse

• death

• ABSENCE OF KNOWN PREDISPOSING FACTORS: is the absence of known underlying diseases or other factors e.g. drugs which can explain the occurrence of the syndrome

RUMOUR SURVEILLANCE

• This system relies on information gather from many sources

• General Objectives:

▪ to provide an early warning sign in detecting potential outbreak within and outside Malaysia

• Specific Objectives:

– to collate rumours on infectious diseases within the country and internationally

– to verify the rumours through investigation for decision on further action or to dismiss it

– to disseminate information about the verified rumours to appropriate parties so that appropriate public health action is taken

Source Of Information For Rumour Surveillance

• Printed media e.g. local newspapers

• Internet

• Television & radio

• Phone calls

• E-mails from public

• E-mail discussion group e.g. ProMed-mail

• Word-of-mouth of public or health staff from different levels

EVENT-BASED

SURVEILLANCE

EXAMPLES OF EVENTS REPORTED :

➢ FLOOD / LANDSLIDE

➢ EXPLOSION AND FIRE

➢ GAS LEAKAGE –AMMONIA /CHLORINE

➢ CARBON MONOXIDE POISONING

➢ CLUSTER OF ARI

EVENT NOTIFICATION

Overview of All Hazard

Public Health Surveillance & Response Functions

Source: WHO. 2014. Early detection, assessment

and response to acute public health events:

Implementation of Early Warning and Response with

a Focus on Event-Based Surveillance (Interim

Version). Geneva, Switzerland.

WHAT IS EVENT-BASED SURVEILLANCE

Event-Based Surveillance (EBS) is defined as;

- The organized and rapid capture of information about eventsthat are a potential risk / concern to public health.

Information

can include rumours and other ad-hoc reports obtained through either; formal channel (established routine reporting systems) or informal channel. (media, health workers and non-governmental organisation reports)

Source : A Guide to Establishing Event-based Surveillance, WHO Western Pacific Region

2008

Objectives of Event-Based Surveillance

To rapidly detect and appropriately respond to acute public health events of any origin, ensuring timely implementation of effective control measures.

• To facilitate early detection and early response towards reportedpublic health events.

• To reduce the public health risk and impact of the events

• To complement the indicator-based surveillance and other surveillance systems.

PUBLIC HEALTH EVENTS DEFINITION

• Any public health event that raises concern, fear and alarm in the community.

• Events which may have a known, suspected or possible impact on human health and require immediate action to reduce the consequences e.g. highly potential for spread and / or high case fatality rates

• Events with unusual disease pattern; events arising outside their usual pattern of occurrence.

• Events where the underlying agent, disease, mode of transmission is new, newly-discovered or as yet unknown at the time of detection.

• Events that constitute a public health threat; i.e. with severe consequences on trade / travel and related to the intentional release of biological or chemical agents

Achievements: Disaster Preparedness Plan

• General Plan

• Plans for disaster due to- Communicable diseases

- Mass casualty incident

- Environmental-linked event

- CBRNe

- Stockpile

• Preparing / finalization of • Preparing plan for human resources

mobilization

• Preparing crisis, violence, terrorism

management plan

Notification to e-Wabak 2011 - 2017

474

2855

2219

2526

1754

2454

2147

472

2854

2213

2504

1693

2305

1891

2 1 6 22 61149

256

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500

1000

1500

2000

2500

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2011 2012 2013 2014 2015 2016 2017

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Total Notification Outbreaks Notification Events Notification

Total Notification 2011 - 2017

472

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1693

2305

1891

2

1

6

22

61

149

256

474

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2219

2526

1754

2454

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500

1000

1500

2000

2500

3000

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1000

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2011 2012 2013 2014 2015 2016 2017

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Outbreaks Notification Events Notification Total Notification

Outbreaks Notification 2011 - 2017

472

2854

2213

2504

1693

2305

1891

0

500

1000

1500

2000

2500

3000

2011 2012 2013 2014 2015 2016 2017

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Outbreaks Notification

Notification of Events 2011 - 2013

2 1 622

61

149

256

0

50

100

150

200

250

300

2011 2012 2013 2014 2015 2016 2017

Event Notification

Activities for Malaysian Field Hospital, Cox

Bazar

International Health Sector

Disease Control Division

1 To

- Plan

- Implement

- Monitor &

- Evaluate

- International Health Regulation (IHR)

2005

- International Point of Entry

- Foreign workers Programme

- Travel Health Programme

2 To be a FOCAL POINT and act as a technical adviser to

other agencies, internationally or nationally, with regards to

issues related to International Health.

3 To coordinate any activities or collaboration between

Disease Control Division and International level.

FUNCTIONS OF INTERNATIONAL HEALTH SECTOR (IHS)

MALAYSIA STRATEGIC WORKPLAN FOR EMERGING DISEASES

AND PUBLIC HEALTH EMERGENCIES (MYSED II)

MySED II

MySED / MySED 1

Reference document for MySED

❑JEE is a method developed by the World Health Organization

(WHO) to enable a participating country to evaluate its capacity

in implementing International Health Regulations (IHR) 2005.

❑Through it, a country may identify its gaps and further

strengthen its capacity accordingly in preventing, detecting and

responding fast against any threat to public health in their

respective countries.

❑Until November 2017, 35 countries have implemented JEE

ratings involving their respective countries. In the assessment

of JEE, these WHO experts will be invited to make an

assessment of the identified “19 focus areas”.

❑Malaysia is planning to invite the WHO experts for JEE in 2nd

or 3rd quarter 2019. MOH Malaysia will call for a meeting with

all related ministries / agencies / stakeholders to discuss further

on this evaluation.

JOINT EXTERNAL EVALUATION (JEE)

(a) Assessment

and Medical care,

staff & equipment

(b) Equipment &

personnel for

transport ill travellers

(c) Trained

personnel for

inspection of

conveyances

(d) ensure save environment:

water, food, waste, wash

rooms & other potential risk

areas - inspection

programmes

(e) Trained staff and

programme for vector

control

Capacity Strengthening at Points

of Entry

POINT OF ENTRY : CORE CAPACITY REQUIREMENTS (ROUTINE)

❑ As of December 2015, the training and hands-on sessions for the permission

to Import and Export Permit of Human Remain, Human Tissues, Micro-

Organism and Pathogenic Substances through the Business Licensing

Electronic Support System (BLESS) has been conducted in all states.

❑ For 2016, all states need to actively carry out training to importing / exporting

agents and must encouraged that these agents apply for their import and

export permits through BLESS (manual application is still accepted).

❑ In 2017, all states were obliged to carry out all activities of Import and Export of

of Human Remain, Human Tissues, Micro-Organism and Pathogenic

Substances permits through BLESS fully (no more manual application).

1 The New Concession Agreement between Ministry of Health (MOH),

Ministry of Home Affairs (MOHA) and FOMEMA was signed on 16th

December 2016.

2 The 17th Cabinet Committee Meeting on Foreign Workers and

Unauthorized workers (JKKPA-PATI) on 17th August 2017 had agreed

that all foreign workers need to undergo few health screenings,

namely :

▪ before departing from their country of origin

▪ one month after arrival in Malaysia

▪ at the end of the first year

▪ at the end of the second year and

▪ at intervals of every two years as long as they are employed in

Malaysia

3 MOH will continue to monitor all clauses in the agreement to ensure

the concession agreement will be followed through and implemented

by FOMEMA Sdn Bhd. This is done through Project Monitoring

Committee (PMC) Meeting held every 4 months, co-chaired by DG of

MOH and DG of JIM.

4 At least 4 meetings will be held to ensure that the quality of medical

examination is maintained

▪ Committee on Quality of Laboratory Services

▪ Committee on Quality of X-ray Services

▪ Technical Committee on Foreign Workers Examination – chair by

PKP

▪ Interagency Meeting on Foreign Workers Examination – chair by

TKPK(KA)

FOREIGN WORKERS MEDICAL EXAMINATION SYSTEM (FWMES) IN

MALAYSIA

Travel health

• IHS, Surveillance Section monitors the health status of international travellers with the focus on

– Pilgrim Hajj Programme

– Yellow Fever Surveillance

No. Common CauseNumber of Patients

(Percentage)

2014

1 Chest Diseases 37,299 (80.6%)

2 Musculoskeletal Diseases 2,994 (6.5%)

3 Skin Diseases 2,375 (5.1%)

4 Ear, Nose and Throat Diseases 2,119 (4.6%)

5 Gastrointestinal Diseases 1,511 (3.3%)

2015

1 Chest Diseases 39,817 (88.5%)

2 Musculoskeletal Diseases 2,269 (5.0)

3 Gastointestinal Diseases 1,154 (2.6%)

4 Skin Diseases 899 (2.0)

5 Cardiovascular Diseases 844 (1.9%)

2016

1 Chest Diseases 37,311(67.8%)

2 Ear, Nose and Throat Diseases 2505(4.6%)

3 Musculoskeletal Diseases 2242(4.1%)

4 Skin Diseases 1696(3.1%)

5 Cardiovascular Diseases 1081(2.0%)

2017

1 Chest Diseases 53122 (59.9%)

2 Musculoskeletal Diseases 3908 (4.4%)

3 Ear, Nose and Throat Diseases 3890 (4.4%)

4 Gastro-intestinal Diseases 2892 (3.3%)

5 Cardiovasular Diseases 2826 (3.2%)

Top 5 Common Causes For Outpatient Attendance Top 5 Common Causes For Inpatient Admission

ACHIEVEMENTS OF IHS 2011 – 2017 – HAJJ PILGRIMS

No. Common CauseNumber of Patients

(Percentage)

2014

1 Chest Diseases 188 (45.3%)

2 Cardiovascular Diseases 88 (21.2%)

3 Metabolic Disorders 58 (14.0%)

4 Gastrointestinal Diseases 51 (12.3%)

5 Psychiatric Disorders 30 (7.2%)

2015

1 Chest Diseases 292 (40.7%)

2 Cardiovascular Diseases 162 (22.6%)

3 Metabolic Disorders 110 (15.3%)

4 Gastrointestinal Diseases 94 (13.1%)

5 Psychiatric Disorders 59 (8.2%)

2016

1 Chest Diseases 353 (40.0%)

2 Cardiovascular Diseases 79 (9.0%)

3 Nuerological Diseases 72 (8.1%)

4 Gastrointestinal Diseases 57 (6.5%)

5 Kidney and Urinary Diseases 53 (6.0%)

2017

1 Chest Diseases 625 (43%)

2 Cardiovascular Diseases 165 911.4%)

3 Metabolic Disorders 147 (10%)

4 Gastrointestinal Diseases 103 (7%)

5 Skin Diseases 68 (4.7%)

YEARTOTAL VISITORS

SCREENED

VISITORS WITH VALID

CERTIFICATEVISITORS QUARANTINED

VISITORS UNDER HEALTH

SURVEILLANCE

2011 31,180 30,963 (99.3%) 175 (0.56%) 42(0.1%)

2012 31,183 30,961 (99.3%) 91 (0.29%) 12 (0.04%)

2013 27,909 27,868 (99.9%) 20 (0.07%) 9 (0.03%)

2014 30,235 30,088 (99.5%) 122 (0.40%) 14 (0.05%)

2015 27,808 27,705 (99.6%) 84 (0.30%) 4 (0.01%)

2016 32,090 31,923 (99.5%) 135 (0.42%) 26 (0.07%)

2017 31183 31055 (99.6%) 72 (0.23%) 6 (0.02%)

YELLOW FEVER SCREENING AT THE INTERNATIONAL ENTRY POINTS

24

19

119

68

2 25 6

4 31

0

20

2011 2012 2013 2014 2015 2016 2017

Number of Application Number of approved

Monitoring of Yellow Fever Vaccination Centre, 2011-2017

ACHIEVEMENTS OF IHS 2011 - 2017

THANK YOU