This webinar is organized by MyICID and Institute for Clinical Research (ICR), NIH, Ministry of Health in conjunction with Neglected Tropical Disease Day 2022. The purpose of this webinar is to refresh and update our knowledge on Dengue fever, which has been overshadowed by COVID-19 since the beginning of the pandemic. Presenter: Dr Norhayati Mokhtar, Public Health Physician at the Vector Borne Disease Sector, Disease Control Division, Ministry of Health Malaysia #dengue #WorldNTDDay #BeatNTDs

1. UPDATES IN VECTOR
CONTROL IN MALAYSIA:
What is new?
Vector Borne Disease Sector
Disease Control Division
Ministry of Health Malaysia
12th February 2022

2. Disclaimer
• This slide was prepared for the Webinar Series on COVID-19 session on
3rd March 2021, by Dr Norhayati Mokhtar, Public Health Physician
at the Vector Borne Disease Sector, Disease Control Division,
Ministry of Health Malaysia.
• This is intended to share within healthcare professionals, not for public.
• This webinar is organised by Malaysian Society of Infection Control and
Infectious Diseases (MyICID) & Institute for Clinical Research, NIH in
conjunction of World NTD Day 2022.

3. Outline of Presentation
1. Dengue situational analysis in Malaysia
2. Vector Control Approaches in dengue prevention &
control in Malaysia
3. Innovations in dengue prevention & control :-
• Wolbachia mosquito
• Sterile Insect Technique (SIT)
• Dengue Forecasting System
4. Summary
3

4. Dengue Situation in Malaysia
4

5. DENGUE SITUATION IN MALAYSIA 2021 & 2022
Dengue Cases
70.8%
(63,939 cases)
Cumulative cases in 2021: 26,365
Cumulative cases in 2020: 90,304
VS
Dengue deaths
Dengue deaths 2021: 20
Dengue deaths 2020: 145
86.2%
(125 deaths)
VS
Case Fatality Rate (CFR)
2021: 0.08% 2020: 0.16%

6. DENGUE SITUATION IN MALAYSIA (EW 5/2022)
Dengue Cases
7.3 %
(244 cases)
Cumulative cases in 2022: 3,573
Cumulative cases in 2021: 3,329
VS
Dengue Deaths
Dengue death in 2022: 0
Dengue death in 2021: 0
VS

7. 7
0
500
1000
1500
2000
2500
3000
3500
2021 2020 5 yr median
Cases
Epid Week
Weekly Dengue Cases in Malaysia
Year 2021, 2020 & 5 years median (2016-2020)

8. DENGUE TRENDS IN MALAYSIA 2013 –2021
0
500
1000
1500
2000
2500
3000
3500
4000
1 7 13 19 25 31 37 43 49 3 9 15 21 27 33 39 45 51 4 10 16 22 28 34 40 46 52 6 12 18 24 30 36 42 48 2 8 14 20 26 32 38 44 50 4 10 16 22 28 34 40 46 52 6 12 18 24 30 36 42 48 2 8 14 20 26 32 38 44 50 4 10 16 22 28 34 40 46 52
2013 2014 2015 2016 2017 2018 2019 2020 2021

9. Number Of Dengue Cases & Deaths
(Year 2000 – 2021)
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Number of Cases 7,103 16,368 32,767 31,545 33,895 39,686 38,556 48,846 49,335 41,486 46,171 19,884 21,900 43,346 108,698 120,836 101,357 83,849 80,615 130,101 90,304 26,365
Number of death 45 50 99 72 102 107 92 98 112 88 134 36 35 92 215 336 237 177 147 182 145 20
0
50
100
150
200
250
300
350
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
Number
of
Death
Number
of
Cases
Year

10. Number Of Dengue Cases & Incidence rate
(Year 2000 – 2021)
10
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Number of case 7,103 16,368 32,767 31,545 33,895 39,686 38,556 48,846 49,335 41,486 46,171 19,884 21,900 43,346 108,69 120,83 101,35 83,849 80,615 130,10 90,304 26,365
Incidence rate 30.5 68.8 133.6 125.9 132.5 151.9 144.7 179.8 177.9 146.6 163.4 69.6 74.7 145.9 361.1 396.4 328.3 258.9 245.3 390.4 276.5 78.0
0.0
50.0
100.0
150.0
200.0
250.0
300.0
350.0
400.0
450.0
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
Incidence
rate
per
100,000
population
Number
of
case

11. 11
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Number of death 45 50 99 72 102 107 92 98 112 88 134 36 35 92 215 336 237 177 147 182 145 20
Case Mortality rate 0.63% 0.31% 0.30% 0.23% 0.30% 0.27% 0.24% 0.20% 0.23% 0.21% 0.29% 0.18% 0.16% 0.21% 0.20% 0.28% 0.23% 0.21% 0.18% 0.14% 0.16% 0.08%
0.00%
0.10%
0.20%
0.30%
0.40%
0.50%
0.60%
0.70%
0
50
100
150
200
250
300
350
400
Case
Mortality
rate
Number
of
death
Year
Number Of Deaths & Case Fatality Rate
(Year 2000 – 2021)

12. DENGUE INCIDENCE RATE BY STATES IN 2021
> 400 per 100,000 population
300 – 399.9 per 100,000 population
200 – 299.9 per 100,000 population
100- 199.9 per 100,000 population
< 100 per 100,000 population
46.0
15.1
5.0
25.4
65.2
3.8
57.5
22.2
46.8
29.4
240.1
22.9
8.2
11.6
164.7
Incidence Rate Malaysia = 78.0 per 100,000 population
12

13. 13
DENGUE CASES & DENGUE SEROTYPE 2013-2021
0
500
1000
1500
2000
2500
3000
3500
4000
1 7 13 19 25 31 37 43 49 3 9 15 21 27 33 39 45 51 4 10 16 22 28 34 40 46 52 6 12 18 24 30 36 42 48 2 8 14 20 26 32 38 44 50 4 10 16 22 28 34 40 46 52 6 12 18 24 30 36 42 48 2 8 14 20 26 32 38 44 50 4 10 16 22 28 34 40 46 52
2013 2014 2015 2016 2017 2018 2019 2020 2021
0%
10%
20%
30%
40%
50%
60%
70%
JAN
MAR
MAY
JUL
SPT
NOV
JAN
MAR
MAY
JUL
SPT
NOV
JAN
MAR
MAY
JUL
SPT
NOV
JAN
MAR
MAY
JUL
SPT
NOV
JAN
MAR
MAY
JUL
SEP
NOV
JAN
MAR
MAY
JUL
SEP
NOV
JAN
MAR
MAY
JUL
SEP
NOV
JAN
MAR
MAY
JUL
SEP
NOV
JAN
MAR
MAY
JUL
SEP
NOV
2013 2014 2015 2016 2017 2018 2019 2020 2021
DENV1 DENV2 DENV3 DENV4

14. Vector Control Approaches in
Dengue Prevention & Control in
Malaysia
14

15. •reducing abundance of vector
population/density to the level that it may
not allow transmission
15
Objective of vector control

16. Vector Control Approaches in Dengue Prevention & Control
1. Source reduction (Penghapusan Tempat Pembiakan,
PTP)
2. Larvaciding
3. Space Spraying (Semburan Ruang Termal, SRT)
4. Targeted Outdoor Residual Spray (ORS)
5. Health promotion
6. Law Enforcement

17. 1. Source reduction of Aedes larvae
• Search & destroy of Aedes breeding places
• Done in 24 hours after case notified in the eDengue system
• Premise coverage in the affected locality must be 100% within 3
days
• 200 meters for single case and 400 meters in outbreak
• Health Inspectorates (PPKP/ PKA/ PA)
➢ District Health Office (Pejabat Kesihatan Daerah,PKD)
➢ Local Council (Pihak Berkuasa Tempatan, PBT eg: MBSA, MBPJ)
• Pest Control Operator (PCO)
Vector Control Approaches in Dengue Prevention & Control

18. Search & destroy activities

19. 2. Larvaciding
▪ Sand granule/ capsule/ solutions
▪ Using Temephos or Bacillus Thuringiensis Israelensis (Bti)
▪ Done at any site that has potential breeding containers eg: back lane /empty
lots/ bushes/ building structure
▪ ‘Community larvaciding’
Vector Control Approaches in Dengue Prevention & Control

20. Abating using sand granule
Mist Blower
Spray can
Spray can

21. Vector Control Approaches in Dengue Prevention & Control
21
By COMBI volunteers (Communication for Behavioural Impact) :-

22. Vector Control Approaches in Dengue Prevention & Control
3. Space Spray of adult Aedes
▪ Done within 24 hours after case notified in eDengue system
▪ Premise coverage in the affected locality must be 80%
▪ 200 meters for single case and 400 meters in outbreak
▪ Indoor and outdoor
▪ Dawn (5 am-7 am) & dusk (5 pm-7 pm); peak biting hours
▪ Encourage use of aerosol spray for closed premises
▪ Thermal fogging must be complimented with ULV in outbreak situation

23. Preparation of fogging machine before space spray at the field

24. Space spraying/fogging

25. Vector Control Approaches in Dengue Prevention & Control
4. Targeted Outdoor Residual Spray (ORS)
▪ New approach initiated by IMR Malaysia
▪ Applying of low dose pyrethroid onto the outer
surfaces where mosquito suspected to hide/rest
▪ The residual activity of the insecticide lasts between
2-3 months
▪ Preventive method in dengue hotspot localities or
areas with recurring dengue
▪ Done at least for 2 cycles of spray; every 3 months
▪ Disadvantage: laborious

26. HEALTH PROMOTION
• Depending on type of dengue cases reported (single case/controlled
outbreak/uncontrolled outbreak/ hotspots) :-
✓Announcement (Siaraya/Hebahan)
✓Hebahan; Mass (TV, radios) & Social Media (Whatsapp, Facebook, Instagram
etc)
✓Banner/ Posters/ Flyers
✓Community mobilization
✓Health Education Kiosk at hotspots area
✓Dialogues
26

27. Vector Control Approaches in Dengue Prevention & Control
27
TV/radios interviews Posters/banners
Announcements

28. LAW ENFORCEMENT
• According to Destruction of Disease-Bearing Insects Act 1975 (DDBIA
1975) : “ The Director General, a medical Officer of Health, an inspector or a public officer authorized
in writing in that behalf by the Director General may compound any offence committed by any person
under this act or any regulations made under this act……….of an amount not exceeding five hundred
ringgit within the time specified in the offer”
• Operasi Gempur Aedes (OGA)
28
Year Premises Inspected Premises Positive Breeding Compounds issued Premises closed
2018 4,688,302 119,418 21,370 120
2019 4,877,369 161,506 24,869 117
2020 4,685,063 175,642 21,748 71
2020 3,953,480 140,415 21,976 52
Source: Bahagian Perkembangan Kesihatan Awam, KKM

29. New Innovative Approaches in Dengue Control
1. Wolbachia Mosquito
2. Sterile Insect Technique (SIT)
3. Dengue Forecasting
29

30. 1. Wolbachia mosquito release

31. Wolbachia inside an insect cell 31
Intracellular bacteria

32. How is Wolbachia transferred to Aedes aegypti mosquito?
32

33. Wolbachia have been proven to block the virus replication in
mosquito
HOW?
i. Boost the natural immune systems
of the mosquito
ii. Consume cholesterol inside the
mosquito
Make the dengue virus harder to
grow
33

34. ➢ Field trial phase by IMR in 2017: all localities shows
reduction in cases
• Operational phase: starts in 7 July 2019 at 11 localities
with high dengue burden
• Operating Budget (staffs, equipments, Wolbachia
insectariums) : Ministry of Health Malaysia (District
Health Offices & State Health Offices)
• Involves multidisciplinary team; Epidemiologists/
Entomologists/ Health Inspectors/ Health Education
Officers/ COMBI team/ community leaders/ residential
building management body/ local municipal.
• Prevention & control activities at Wolbachia mosquito
release site: NO fogging
• Dengue Enforcement as usual
34

35. CRITERIA FOR
LOCALITY
SELECTION
a. High burden Dengue cases/ recalcitrant dengue
hotspots
b. Type of premises (high rise building): reduction
of dengue cases in Wolbachia mosquitoes
release sites best seen in the clustered high rise
or flats
c. Natural boundaries;
▪ river
▪ Highways
▪ Park/open space
▪ Fields
d. No industrial sites
e. Area of at least 0.6 km square
f. Number of households
g. Good public co-operation & support
• Score (1-5) 1= the most inappropriate, 5= the most
appropriate

36. 2 Wolbachia based strategies
Malaysia adopts
Replacement Strategy
The hallmark of replacement
strategy: to REPLACE wild
Aedes aegypti populations with
Wolbachia infected Aedes (WIA)
aegypti populations .
Courtesy from IMR

37. States Involved In Wolbachia mosquito release
37
• All these 22 sites: recalcitrant dengue hotspots
• High rise building
COHORT 1
7 July 2019
11 localities
▪ Selangor : 8 localities
▪ WPKL & Putrajaya: 3
localities
2 localities
COHORT 2
November 2019
8 localities
▪ WPKL & Putrajaya : 3
localities
▪ Pulau Pinang : 3
localities
▪ Selangor : 2 localities
COHORT 3
2021 - 2022
11 localities
▪ WPKL & Putrajaya : 1
locality
▪ Kelantan : 2 localities
▪ Pulau Pinang : 2 localities
▪ Selangor : 2 localities
▪ Johor : 1 locality
▪ Melaka: 1 locality
▪ N. Sembilan: 1 locality
▪ Pahang : 1 locality
3 localities
10 localities
7 localities

38. Outcome indicators :-
2 important endpoints:-
1. Epidemiological Endpoints
❖Weekly confirmed dengue cases reported in the area
2. 2. Entomological Endpoints
❖Wolbachia frequency (%) in the environment
38

39. Dengue cases 6 months before & after 2 years of Wolbachia mosquito release
39
Code Locality
Time frame
Dengue cases 6
month pre- release
Dengue cases 24
months post- release
Differences (%)
W01. Kelana 23 1 95.7
W02. Baiduri 79 0 100
W03. Damansara 47 1 97.9
W04. Lavendar 4 1 75
W05. Perdana 78 3 96.2
W06. D.Mentari 92 0 100
W07. Otomobil 200 2 99
W08. Subang Suria 84 2 97
W09. Penara 77 4 94.8
W10. Razak 12 2 83.3
W11. Sri Rakyat 13 1 92.3
TOTAL 709 17 97.6

40. 23
79
47
4
78
92
200
84
77
12 13
1 0 1 1 3 0 2 2 4 2 1
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
0
20
40
60
80
100
120
140
160
180
200
Case
reduction
(%)
No.
of
dengue
case
6 MTH PRE 6 MTH POST2YR REDUCTION (%)
DENGUE CASES 6 MONTHS BEFORE & 24 MONTHS AFTER
WOLBACHIA MOSQUITO RELEASE

41. Dengue Cases at Wolbachia mosquito released locality
41
16.5
17
17.5
18
18.5
19
19.5
20
0
2
4
6
8
10
12
14
16
18
20
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 03 06 09 12 15 18 21 24 27 30 33 36 39 42 45 48 51 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52
Daftar Pelepasan Telur Pelepasan Nyamuk Dewasa
APARTMENT PERDANA - SEKSYEN 13
BIL KES
EPID WEEK

42. Dengue Cases at Wolbachia mosquito released locality
42
0
2
4
6
8
10
12
0
2
4
6
8
10
12
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 03 06 09 12 15 18 21 24 27 30 33 36 39 42 45 48 51 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52
Daftar Pelepasan Nyamuk Dewasa Pelepasan Telur
PELANGI DAMANSARA (BLOK D-K)
BIL KES
MINGGU EPID

43. Dengue Cases at Wolbachia mosquito released locality
43

44. PREPARATION BEFORE RELEASE OF WOLBACHIA MOSQUITO (EGGS)
STAGE)

45. PREPARATION BEFORE RELEASE OF ADULT WOLBACHIA MOSQUITOES

46. 2. STERILE INSECT TECHNIQUE (SIT)
• The SIT was among the first biological insect control methods
designed for area wide application (AW-A)
• Insect control methods in the first 70 years of the 20th century
were based largely on chemical insecticides and it has unsolved
resistance and environmental problem
• IMR conducted trial phase study since 2019
• Radiation process done at Malaysian Nuclear Agency
Nazni wt al., 2021

47. ✓ “Birth control of insects”, for suppression or elimination of target pest population
(Dyck et al, 2005)
✓ It is an environment-friendly, species-specific, cost-effective, sustainable
biological pest control method
✓ Radiation sterilised insects are considered radioactivity free, because no
residual radioactivity remains on them (Whitten & Mahon, 2005)
✓ Developed in 1950 by
Dr. R. Bushland Dr. E. Knipling
(www.worldfoodprize.org)
(Dyck et al, 2005; Alphey et al, 2010)
Nazni wt al., 2021
Sterile Insect Technique

48. Eggs do not
hatch=population
crashed
BIRTH CONTROL (BC)
WHAT IS SIT?

49. Sterile Insect Technique
+
Radiation
Pupae
Sterile Male Female
Insect
No Offspring
Nazni wt al., 2021

50. 2 Phases of study:
PHASE 1: Laboratory experiments
Optimal dosage, Life-cycle - longevity, Sterility status, susceptibility to dengue
virus, TEM on salivary gland
PHASE 2: Open Field Release
( a ) Mass rearing
( b ) Site selection – Hot spot
( c ) Community engagement
( d ) Surveillance of Aedes aegypti population
Nazni wt al., 2021

51. Prior to field release
• 100 sterile males per cup (by scooping)
• Daily sucrose feeding ( 1-2 days) until release day
Nazni wt al., 2021

52. Overall Ae. aegypti Larval Density
B
a
s
e
l
i
n
e
1
B
a
s
e
l
i
n
e
2
B
a
s
e
l
i
n
e
3
1
1
J
a
n
2
0
2
1
1
8
J
a
n
2
0
2
1
2
5
J
a
n
2
0
2
1
2
F
e
b
2
0
2
1
8
F
e
b
2
0
2
1
1
5
F
e
b
2
0
2
1
2
2
F
e
b
2
0
2
1
1
M
a
r
c
h
2
0
2
1
8
M
a
r
c
h
2
0
2
1
1
5
M
a
r
c
h
2
0
2
1
2
2
M
a
r
c
h
2
0
2
1
2
9
M
a
r
c
h
2
0
2
1
5
A
p
r
i
l
2
0
2
1
1
2
A
p
r
i
l
2
0
2
1
1
9
A
p
r
i
l
2
0
2
1
2
6
A
p
r
i
l
2
0
2
1
0
10
20
30
40
Kota Laksamana (Control site)
Taman Tasik Utama (Release site)
Larval
Density
96.74% suppression of Ae. aegypti larvae in the release site
compared to control site after 16th release.
Nazni wt al., 2021

53. Dengue Cases Reported at TTU

54. 3. DENGUE FORECASTING
• System that forecasts dengue outbreaks,
with sufficient lead time to allow for
effective interventions to be implemented
using seasonal climate data
• UK Space Agency International Partnership
Programme (IPP): Dengue Forecasting
Model Satellite-Based System (D-MOSS);
pilot project since November 2021
• Decision support tools
• Predicts outbreak 6 months in advance
54

55. 55
❖ 20 years of historical Earth
Observation data from
satellites:-
• Temperature
• Humidity
• Rainfall
• Soil moisture
• Land cover
• Wind Speed and
direction
❖ 10 years Epidemiological
data:-
dengue cases

56. 56
Dashboard

57. STRATIFICATION OF DENGUE LOCALITY
➢Priority localities (lokaliti keutamaan): 4 categories
❖Priority 1 : uncontrolled outbreak/ hotspots in previous year
❖Priority 2 : controlled outbreak in previous year
❖Priority 3 : 1 case in previous year
❖Priority 4 : no case reported in previous year
➢Priority premises (premis keutamaan): vary with states / districts

58. Summary
1. Dengue prevention & control is everyone’s responsibility. Continuous
efforts are required to sustain cooperation from communities in
maintaining search & destroy activities.
2. During Covid-19 pandemic : competing priorities for financial support,
attention & synergistic collaboration from all stakeholders; need for re-
focus for essential duty
3. Paradigm shift : from control mode to preventive mode by using dengue
forecasting system
4. Wolbachia mosquito operationalization will be expanded to other high
dengue burden localities
5. No ‘magic bullet’ & stand-alone tool to combat dengue; Integrated Vector
Control Management

59. 59

60. ACKNOWLEDGEMENTS
• Director General of Health, Tan Abdullah
• Dr Nazni WA, Institute for Medical Research (IMR)
• Dr Nurul Husna AH, Institute for Medical Research (IMR)
• PKD Petaling Vector Unit
• COMBI Negeri Pulau Pinang

61. Thank you