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
0
500
1000
1500
2000
2500
3000
2011 2012 2013 2014 2015 2016 2017
Nu
mb
er o
f O
utb
reak
s N
oti
fica
tio
n
Year
Total Notification Outbreaks Notification Events Notification
Total Notification 2011 - 2017
472
2854
22132504
1693
2305
1891
2
1
6
22
61
149
256
474
2855
2219
2526
1754
2454
2147
0
500
1000
1500
2000
2500
3000
0
500
1000
1500
2000
2500
3000
2011 2012 2013 2014 2015 2016 2017
Nu
mb
er o
f O
utb
reak
s N
oti
fica
tio
n
Year
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
Nu
mb
er o
f O
utb
reak
s N
oti
fica
tio
n
Year
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
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