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.

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