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Strengthening ncd surveillance in malaysia, asean ncd forum 2013

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Zainal Ariffin Omar and Feisul Idzwan Mustapha. Strengthening NCD Surveillance in Malaysia. 15 September 2013. Working paper presented at the ASEAN Regional Forum on NCDs. Manila, Philippines.

Zainal Ariffin Omar and Feisul Idzwan Mustapha. Strengthening NCD Surveillance in Malaysia. 15 September 2013. Working paper presented at the ASEAN Regional Forum on NCDs. Manila, Philippines.

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  • 1. Ministry of Health Malaysia Strengthening NCD Surveillance in Malaysia Zainal Ariffin Omar Consultant in Public Health Disease Control Division, MOH Malaysia ASEAN Regional Forum on NCD 15 October 2013 Philippines dr.zainal@moh.gov.my
  • 2. Burden of Diabetes in Malaysia: (Adults age 18 years & above) Population-based surveys 25 5,000,000 Current projection 20 4,500,000 Prevalence (%) 3,500,000 15 3,000,000 2,500,000 10 2,000,000 Estimated population 4,000,000 1,500,000 5 1,000,000 500,000 0 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Year Est. population, 2006 Est. population, 2011 Prevalence projection, 2006 2 Prevalence projection, 2011
  • 3. Admissions to MOH Hospitals due to Circulatory Diseases & Cancer Hospital admission data 200,000 y = 13099e0.020x R² = 0.795 180,000 160,000 140,000 y = 53166e0.052x R² = 0.871 120,000 100,000 80,000 60,000 40,000 20,000 0 2005 2006 2007 Circulatory diseases 2008 2009 2010 2011 Malignant neoplasms 2012 2013 2014 2015 2016 Projected, Circulatory diseases 2017 2018 2019 Projected, Cancer 2020 3
  • 4. Disease-based registries Primary Renal Diseases New dialysis patients 9000 y = 314.5x + 1735. R² = 0.963 8000 7000 6000 5000 4000 3000 2000 Since 2003, diabetes accounted for > 50% of the primary renal disease of new dialysis patients 1000 0 New dialysis patients Projected new dialysis patients 4
  • 5. Seven Strategies: 1. 2. 3. National Strategic Plan for Non-Communicable Diseases (NSP-NCD) 2010-2014 • • • 4. 5. 6. 7. Presented and approved by the Cabinet on 17 December 2010 Provides the framework for strengthening NCD prevention & control program in Malaysia Adopts the “whole-of-government” and “whole-ofsociety approach” Prevention and Promotion Clinical Management Increasing Patient Compliance Action with NGOs, Professional Bodies & Other Stakeholders Monitoring, Research and Surveillance Capacity Building Policy and Regulatory interventions 5
  • 6. National Health and Morbidity Surveys (NHMS) • Population-based survey conducted by MOH • NHMS I (1986), NHMS II (1996) & NHMS III (2006) • Latest NHMS 2011 • For NCD risk factors, now conducted every 4 years • Based on WHO STEPwise Methodology • Sampling • National Household Sampling Frame made up of Enumeration Blocks (EBs) derived from the Population and Housing Census, Malaysia (2010) • Multistage Random Sampling (28 strata) 6
  • 7. NHMS 2011 (Volume II, NCD risk factors) • Full report published in January 2012. • Pdf copy available from the Institute for Public Health (IKU). • Fact sheet available at MOH website http://www.moh.gov.my/v/NCDs. • Results were presented at the 15th NIH Scientific Meeting 2012. • Powerpoints available at the Institute for Health Management (IHM) website http://www.ihm.moh.gov.my/index.php/e n/power-point-presentation-15th-nihscientific-meeting. 7
  • 8. 65th World Health Assembly (May 2012): Decided to adopt a global target of a 25% reduction in premature mortality from NCD by 2025. 66th World Health Assembly (May 2013): Adoption of the Global Action plan for the Prevention and Control of NCDs (2013-2020), including 25 NCD indicators with 9 voluntary global targets. 8
  • 9. Global Monitoring Framework for NCDs Indicator Targets 1. Premature mortality from NCD 25% relative reduction in risk of dying 2. Harmful use of alcohol 10% relative reduction 3. Physical inactivity 10% relative reduction 4. Salt intake 30% relative reduction in mean population intake 5. Tobacco use 30% relative reduction 6. Hypertension Contain the prevalence 7. Diabetes & obesity Contain the prevalence 8. Drug therapy to prevent heart attacks & strokes At least 50% of eligible people receive therapy 9. Essential NCD medicines & basic technologies to treat major NCDs Availability & affordability 9 Note: Targets for year 2025, against baseline of year 2010. Reporting to the United Nations every five years (next will be in 2015)
  • 10. Mortality and morbidity Indicators Action for Malaysia 1. Unconditional probability of dying between ages 30 and 70 years from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases. Discussion with the Health Informatics Centre, MOH, National Registration Department, and the National Statistics Department • Non-medically ertified deaths i.e. implementation of verbal autopsy 2. Cancer incidence, by type of cancer, per 100,000 population Strengthening implementation of the National Cancer Registry 10
  • 11. Risk Factors (Behavioural) Indicators Action for Malaysia 3. Harmful use of alcohol: Total (recorded and unrecorded) alcohol per capita (15+ years old) consumption within a calendar year in litres of pure alcohol, as appropriate, within the national context. Propose to use this indicator. 4. Harmful use of alcohol: Age-standardized prevalence of heavy episodic drinking among adolescents and adults, as appropriate, within the national context. Propose to use this indicator. Data collected via NHMS. 5. Harmful use of alcohol: Alcohol-related morbidity and mortality among adolescents and adults, as appropriate, within the national context. Countries will select indicator(s) of harmful use of alcohol, as appropriate to national context and in line with WHO’s global strategy to reduce the harmful use of alcohol 11
  • 12. Risk Factors (Behavioural) Indicators Action for Malaysia 6. Age-standardized prevalence of persons (aged 18+ years) consuming less than five total servings (400 grams) of fruit and vegetables per day. Data collected via NHMS. 7. Prevalence of insufficiently physically active adolescents (defined as less than 60 minutes of moderate to vigorous intensity activity daily). Data collected via Global School Health Survey (GSHS). First done in 2012. 8. Age-standardized prevalence of insufficiently physically active persons aged 18+ years (defined as less than 150 minutes of moderate-intensity activity per week, or equivalent). Data collected via NHMS. 12
  • 13. Risk Factors (Behavioural) Indicators Action for Malaysia 9. Age-standardized mean population intake of salt (sodium chloride) per day in grams in persons aged 18+ years. To develop new methodology for data collection (with Institute for Public Health, MOH). 10. Age-standardized mean proportion of total energy intake from saturated fatty acids in persons aged 18+ years. Need to conduct a Malaysian Adult Nutrition Survey Or need new methodology? (with Institute for Public Health, MOH). 11. Prevalence of current tobacco use among adolescents. Data collected via Global School Health Survey (GSHS). 12. Age-standardized prevalence of current tobacco use among persons aged 18+ years. Data collected via NHMS. 13
  • 14. Risk Factors (Biological) Indicators Action for Malaysia 13. Age-standardized prevalence of raised Data collected via NHMS. blood glucose/diabetes among persons aged 18+ years (defined as fasting plasma glucose value ≥7.0 mmol/L (126 mg/dl) or on medication for raised blood glucose). 14. Age-standardized prevalence of raised Data collected via NHMS. blood pressure among persons aged 18+ years (defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg); and mean systolic blood pressure. 14
  • 15. Risk Factors (Biological) Indicators Action for Malaysia 15. Prevalence of overweight and obesity in adolescents (defined according to the WHO growth reference for school-aged children and adolescents, overweight – one standard deviation body mass index for age and sex, and obese – two standard deviations body mass index for age and sex). Data collected via NHMS or GSHS. 16. Age-standardized prevalence of overweight and obesity in persons aged 18+ years (defined as body mass index ≥25 kg/m² for overweight and body mass index ≥30 kg/m² for obesity). Data collected via NHMS. 17. Age-standardized prevalence of raised total cholesterol among persons aged 18+ years (defined as total cholesterol ≥5.0 mmol/L or 190 mg/dl); and mean total cholesterol. Data collected via NHMS. 15
  • 16. National Systems Response Indicators Action for Malaysia 18. Proportion of women between the ages of 30– 49 screened for cervical cancer at least once, or more often, and for lower or higher age groups according to national programmes or policies. Existing paper-based return under the Family Health Development Division, MOH 19. Proportion of eligible persons (defined as aged 40 years and over with a 10-year cardiovascular risk ≥30%, including those with existing cardiovascular disease) receiving drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes. To add on to NHMS (to discuss further with Institute for Public Health on sample size required). Or consider separate survey. 20. Availability and affordability of quality, safe and efficacious essential NCD medicines, including generics, and basic technologies in both public and private facilities. Policy / program review. 16
  • 17. National Systems Response Indicators Action for Malaysia 21. Vaccination coverage against hepatitis B virus monitored by number of third doses of Hep-B vaccine (HepB3) administered to infants. Existing paper-based return under the Family Health Development Division, MOH. 22. Availability, as appropriate, if cost-effective and affordable, of vaccines against human papillomavirus, according to national programmes and policies. Policy / program review. 23. Policies to reduce the impact on children of marketing of foods and non-alcoholic beverages high in saturated fats, trans-fatty acids, free sugars, or salt. Policy / program review. 17
  • 18. National Systems Response Indicators Action for Malaysia 24. Access to palliative care assessed by morphine- Policy / program review. equivalent consumption of strong opioid analgesics (excluding methadone) per death from cancer. 25. Adoption of national policies that limit saturated fatty acids and virtually eliminate partially hydrogenated vegetable oils in the food supply, as appropriate, within the national context and national programmes. Policy / program review. 18
  • 19. National Diabetes Registry • Web-based application. • Went live on 1 January 2011. • Supports the implementation of the annual “Diabetes Clinical Audit” amongst Type 2 Diabetes patients in MOH Health Clinics. • First report, “NDR Report, Volume 1, 20092012” was published in August 2013, available at the MOH website http://www.moh.gov.my/v/NCDs. 19
  • 20. Number of Active Registered Patients; as of 31 July 2013 States Johor Kedah Kelantan Melaka N.Sembilan Pahang Perak Perlis P.Pinang Sabah Sarawak Selangor Terengganu WPKL WP Labuan WP Putrajaya Malaysia No. of active patients 90,615 41,808 26,345 35,331 42,079 38,503 67,414 12,714 38,387 11,340 51,327 93,591 18,550 28,385 717 2,141 599,247 20
  • 21. Glycaemic Control: Percentage of T2DM Patients with HbA1c <6.5%, 2009 to 2012 2009 Johor Kedah Kelantan Melaka Negeri Sembilan Pahang Perak Perlis Pulau Pinang Sabah Sarawak Selangor Terengganu WP Kuala Lumpur WP Labuan WP Putrajaya Malaysia 2010 14.0 8.5 8.7 18.4 13.9 13.4 14.5 30.6 12.3 22.6 7.8 15.8 19.9 12.6 n.a. 15.6 13.3 2011 18.3 12.8 9.2 15.3 19.6 19.9 16.3 24.3 18.5 19.6 3.6 25.2 20.5 27.9 30.8 26.2 17.2 2012 14.4 12.3 12.5 16.9 17.8 13.4 13.9 26.1 19.3 25.9 6.4 15.1 17.9 17.9 23.1 15.1 15.6 17.5 15.8 11.3 21.7 19.7 15.1 18.1 27.9 16.5 28.5 7.0 18.4 16.2 24.3 53.5 29.6 18.1 21
  • 22. Diabetes Clinical Audit (2012) Variable Targets HbA1c < 6.5 % BP : Systolic Total no. of Meeting target tests (%) Mean 95% CI 99,823 23.7 8.1 8.1 - 8.1 < 130 mmHg 121,751 47.6 135.5 135.4 - 135.6 BP: Diastolic < 80 mmHg 121,726 67.2 78.4 78.3 - 78.4 Blood pressure < 130 / 80 mmHg 121,698 40.9 Total cholesterol < 4.5 mmol/l 101,286 28.5 5.2 5.2 - 5.2 TG HDL LDL ≤ 1.7 mmol/l ≥ 1.1 mmol/l ≤ 2.6 mmol/l 101,008 76,214 75,734 60.6 65.5 37.8 1.8 1.3 3.1 1.8 - 1.8 1.3 - 1.3 3.1 - 3.1 BMI < 23 kg/m2 108,559 16.6 27.4 27.3 - 27.4 35,520 55,493 33.6 14.4 94.0 90.7 93.9 - 94.1 90.6 - 90.8 < 90 cm (Male) Waist circumference < 80 cm (Female) Total: 130,340 Patients 22
  • 23. Diabetes Clinical Audit (2009-2012) Anti-Diabetics 2009 2010 2011 2012 Metformin 81.7% 85.7% 82.3% 82.2% Sulphonylureas 65.2% 62.9% 59.5% 56.6% Alpha-glucosidase inhibitors 4.7% 5.9% 6.5% 4.8% Insulin 12.0% 11.9% 17.1% 21.3% Monotherapy (OHA) 33.6% 34.1% 27.8% 27.3% >= 2 OHA 51.1% 51.7% 48.7% 45.5% OHA + insulin 8.8% 8.9% 13.2% 16.2% Diet only 3.4% 2.3% 6.4% 5.9% 23
  • 24. Next steps to strengthen NCD surveillance in Malaysia • Discussions with relevant stakeholders to address the issue of non-medically certified deaths. • Strengthening NHMS for NCD risk factors to cater for salt, fat intake, and drug therapy. • Situational analysis on fat intake and marketing of food and nonalcoholic drinks to children (with NIH). • Strengthen NCD surveillance data collection under routine paperbased returns. • WHO will be producing “process indicators” by end of 2013. We will adopt and adapt these indicators to meet our current needs for annual KPI and Outcome-based Budgeting (OBB). 24
  • 25. Thank you dr.zainal@moh.gov.my 25