Paper presented at 8th National Public Health Conference. Hotel Equatorial, Melaka. 2-4th August 2016

1. ECOSYSTEM APPROACH TO DENGUE CONTROL
PETALING DISTRICT
DR.MOHAMED PAID YUSOF
PUBLIC HEALTH MEDICINE SPECIALIST

2. PROBLEM: DENGUE
▪ Dengue is a common tropical disease affecting many different countries
globally and is a major public health burden worldwide.
▪ Malaysia is among those countries that are worse affected, with
recorded cases rising from 32 cases per 100,000 population in 2000 to
361 cases per 100,000 population in 2014.
▪ Until June 2016, Selangor state was the major contributor to the national
burden with more than half of the cases recorded belonging to Selangor.

3. DENGUE SITUATION IN MALAYSIA,
UP TO EPIDEMIOLOGY WEEK 22, 2016
State Case Death
Perlis 83 1
Kedah 356 1
Penang 1,765 10
Perak 1,945 4
Selangor 27,166 44
Federal Territory of Kuala Lumpur & Putrajaya 3,712 5
Negeri Sembilan 1,358 10
Melaka 1,029 1
Johor 6,857 10
Pahang 1,231 6
Terengganu 1,519 13
Kelantan 1,064 1
Sarawak 1,216 4
Sabah 1,296 1
Labuan 3 0
Malaysia 50,600 111

4. DENGUE CONTROL
▪ Dengue control programmes consist of 3 major components;
▪ Vector control,
▪ Monitoring and surveillance
▪ Community participation and enforcement
▪ Monitoring and surveillance has led to better reporting of the disease,
more widespread public knowledge an early treatment-seeking
behaviour.
▪ Community participation and community education campaigns and
enforcement via premise inspections for mosquito breeding sites have
been introduced to increase dengue awareness and preventive efforts

5. DENGUE CONTROL
▪ However, the efforts has not diminished the mosquito
population nor disease burden.
▪ Most of the dengue cases reported were mainly from
the urbanites where factors such as high density
population and rapid development favour dengue
transmission.

6. THE CHALLENGES OF DENGUE CONTROL
PROGRAMME IN PETALING DISTRICT
▪ Mainly due to the effect of urbanisation and rapid
development which includes:
▪ Indiscriminate dumping of garbage results from poor garbage
maintenance particularly in the low to medium cost apartments.
▪ Construction site acts as a breeding ground for the mosquitoes.
▪ Difficulty in starting and sustaining community mobilization
programme among the community.
▪ Intermittent rain and hot weather that promote good
environment for mosquitoes breeding.

7. SETTING: PETALING DISTRICT
▪ Petaling District is a district located in the state of Selangor
in Malaysia.
▪ Middle of Klang Valley.
▪ Hub of Malaysian industries and commerce.
▪ Encompasses an area of 484.32 km², population in 2014
1,928,900; Malays (51%); China (35%); India (12%); Others (2%)
and a population density of 3,700/km².
▪ Highly urbanized district Divided and delegated into the
three local municipalities:
▪ Majlis Bandaraya Shah Alam; Majlis Bandaraya Petaling
Jaya and Majlis Perbandaran Subang Jaya

8. BURDEN OF DISEASE
▪ The dengue incidence in Petaling District is almost four times that of the national figure,
which is 1,205 cases per 100,000 population.
▪ The dengue cases also continued to rise exponentially in 2014 onwards as shown in
Figure 1.
0
5000
10000
15000
20000
25000
30000
2011 2012 2013 2014 2015
Denggi Denggi Berdarah Mati
Dengue Fever
Dengue Hemorrhagic Fever
Figure 1: Number of dengue cases from 2011 to 2015 in Petaling district.

9. BURDEN OF DISEASE
▪ In comparison with all the health districts in Malaysia, Petaling district was at the top
rank with 233 case reported in epid week 22
0 50 100 150 200 250
Petaling
Hulu Langat
Johor Bahru
Klang
Gombak
Sibu
Kepong
Sepang
Seremban
Titiwangsa
Lembah Pantai
Hulu Selangor
Kuantan
Kinta
Cheras
Total Case
Figure 2 : Top 15 Dengue Cases reported according to district in Malaysia, Epid week 22, 2016.

10. APPROACH PRIOR TO 2015….
▪ Case based approach
▪ Control activities carried out were according to number of cases
notified to the District Health Office.
▪ Problem:
▪ Coverage was; Scattered
According to cases
Geographically limited.
▪ There were no preventive measures in place.
▪ Successful broad scale application was a challenge for the health office.
▪ Approach to dengue control was more reactive than preventive.

11. “GREATER EMPHASIS SHOULD BE PLACED ON
PROACTIVE STRATEGIES THAT AIM TO PREVENT,
DIMINISH, OR ELIMINATE TRANSMISSION”
ACHEE ET AL,
CRITICAL ASSESSMENT OF VECTOR CONTROL FOR DENGUE PREVENTION
2015

12. AFTER 2015…
▪ The ecosystem approach was introduced in Petaling District.
▪ Novel approach to combat dengue due to the rising incidence of the
disease.
▪ Petaling was the sole health office that applied this system in a district
wide scale.
▪ Under this approach, the district was divided into 17 ecosystems in its
3 town councils:
i. Shah Alam Town Council - 5 ecosystems
ii. Petaling Jaya Town Council - 7 ecosystems
iii. Subang Jaya Town Council - 5 ecosystems

13. ECOSYSTEM APPROACH TO DENGUE CONTROL
▪ Each ecosystem is further divided into localities. District of Petaling has
2,023 localities and each ecosystem has different number of localities.
▪ For example, ecosystem 1 has 138 localities and ecosystem 2 has 85
localities.
PBT Ecosystem No. of locality
MBSA 5 702
MBPJ 7 538
MPSJ 5 783
Total 17 2,023

14. LOCALITIES IN SHAH ALAM TOWN COUNCIL
ECO 4 (171 Localities)
ECO 5 (260 Localities)
ECO 1 (138 Localities)
ECO 2 (85 Localities)
ECO 3 (47 Localities)

15. ECOSYSTEM APPROACH TO DENGUE CONTROL
▪ Each ecosystem is placed under an Assistant Officer of
Environmental Health
▪ Who plans and coordinates prevention and control activities
▪ Need to be familiar and well equipped with knowledge of their
respective ecosystem
▪ Identify problematic localities.
▪ Each officer is supported by a team of Public Health Assistants
and a General Assistant

16. ECOSYSTEM APPROACH TO DENGUE CONTROL
▪ This decentralized, community based approach centres around
environmental management based on risk assessment.
▪ The risk assessment for each ecosystem identifies the locality
at risk by spotting conditions such as;
▪ Open land
▪ Abandoned house
▪ Blocked drainage
▪ Common public area
▪ Construction sites
▪ Stores

17. ECOSYSTEM APPROACH: MAIN ACTIVITIES
▪ The main activities in the ecosystem approach focuses on prevention,
rather than control.
▪ Preventive activities include;
▪ Destruction of breeding sites
▪ Larvaciding
▪ Ultra-low volume fogging
▪ Community clean up
▪ Health education and awareness
▪ The planned preventive activities involve multiple agencies including
health authorities, town council, enforcement officers, volunteers, non-
governmental organizations and community in the specific locality.

18. ECOSYSTEM APPROACH: RELEVANT CHANGES
0
200
400
600
800
1000
1200
1400
1600
1800
2000
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53
2014 2015 2016
Figure 3: Number of dengue cases notification from 2014 to 2016 according to Epidemiological
Week, Petaling district, Selangor

19. ECOSYSTEM APPROACH: RELEVANT CHANGES
▪ Vector control teams provided personalized and comprehensive
care according to ecosystem needs
▪ Expected to know the environment, community and its risks well enough
to coordinate activities.
▪ Encourages and improves community participation which is vital for the
battle against dengue.
▪ There was a shift away from a standard nationwide ‘top-down’
approach to
▪ Risk based
▪ Multi-agency and community partnership
▪ To resolve environmental sanitation and vector control problems.

20. LESSONS LEARNT
▪ Preventive and control activities should be flexible and tailored
according to the geographical suitability.
▪ Despite large geographical and different municipalities,
sufficient human resource and good logistics support makes it
possible to implement the ecosystem approach.
▪ Ideally, each ecosystem has an officer in charge with adequate
assistants to carry out respective preventive and control
activities. However, due to limited staffing, roles are sometimes
interchangeable which may increase workload.

21. LESSONS LEARNT
▪ Dengue control is complex, due to factors external to the
health sector, which are important measures in improving
disease and dispersal of its vector.
▪ The effectiveness of an ecosystem approach can also be
measured through peoples’ knowledge, attitude and
willingness to participate in preventive programmes.
▪ An overall feedback mechanism on the implemented
programme could also be established to gauge effectiveness
of the programme.

22. CONCLUSION
▪ Many of the conventional methods to dengue control
are not applicable in high endemic areas
▪ The approach to dengue control should be flexible and
tailored according to geographical suitability.
▪ Therefore, the ecosystem approach to dengue control is
highly recommended in these areas.