Strengthening ncd surveillance in malaysia, asean ncd forum 2013

Strengthening NCD Surveillance in Malaysia

Zainal Ariffin OmarConsultant in Public Health

Disease Control Division, MOH Malaysia

ASEAN Regional Forum on NCD15 October 2013

Philippines

[email protected]

Ministry of Health Malaysia

Burden of Diabetes in Malaysia: (Adults age 18 years & above)

2

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 20200

5

10

15

20

25

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

4,500,000

5,000,000

Est. population, 2006 Est. population, 2011Prevalence projection, 2006 Prevalence projection, 2011

Year

Prev

alen

ce (%

)

Estim

ated

pop

ulat

ion

Current projection

Population-based surveys

Admissions to MOH Hospitals due to Circulatory Diseases & Cancer

32005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000f(x) = 130995.317891302 exp( 0.0208068181238924 x )R² = 0.795883029335026

f(x) = 53165.9323729276 exp( 0.0523021022959144 x )R² = 0.871588256039902

Circulatory diseases Projected, Circulatory diseasesMalignant neoplasms Projected, Cancer

Hospital admission data

Primary Renal Diseases

420

0120

0220

0320

0420

0520

0620

0720

0820

0920

1020

1120

1220

1320

1420

1520

1620

1720

1820

1920

200

500

1000

1500

2000

2500

3000

3500

4000

4500

5000f(x) = 314.50303030303 x + 1735.73333333333R² = 0.963416157884089

New dialysis patients

New dialysis patients Projected new dialysis patients

Since 2003, diabetes accounted for > 50% of the primary renal disease of new dialysis patients

Disease-based registries

National Strategic Plan for Non-Communicable Diseases (NSP-NCD) 2010-2014

• 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-of-society approach”

Seven Strategies:1. Prevention and Promotion2. Clinical Management3. Increasing Patient

Compliance4. Action with NGOs,

Professional Bodies & Other Stakeholders

5. Monitoring, Research and Surveillance

6. Capacity Building7. Policy and Regulatory

interventions

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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)

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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/en/power-point-presentation-15th-nih-scientific-meeting.

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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.

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Global Monitoring Framework for NCDsIndicator 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

Note: Targets for year 2025, against baseline of year 2010. Reporting to the United Nations every five years (next will be in 2015)

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Mortality and morbidityIndicators 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

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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

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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.

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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 SurveyOr 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.

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Risk Factors (Biological)Indicators Action for Malaysia

13. Age-standardized prevalence of raised 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).

Data collected via NHMS.

14. Age-standardized prevalence of raised 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.

Data collected via NHMS.

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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

National Systems ResponseIndicators 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.

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National Systems ResponseIndicators 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.

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National Systems ResponseIndicators Action for Malaysia

24. Access to palliative care assessed by morphine-equivalent consumption of strong opioid analgesics (excluding methadone) per death from cancer.

Policy / program review.

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.

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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, 2009-2012” was published in August 2013, available at the MOH website http://www.moh.gov.my/v/NCDs.

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Number of Active Registered Patients; as of 31 July 2013

States No. of active patientsJohor 90,615Kedah 41,808Kelantan 26,345Melaka 35,331N.Sembilan 42,079Pahang 38,503Perak 67,414Perlis 12,714P.Pinang 38,387Sabah 11,340Sarawak 51,327Selangor 93,591Terengganu 18,550WPKL 28,385WP Labuan 717WP Putrajaya 2,141Malaysia 599,247

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Glycaemic Control: Percentage of T2DM Patients with HbA1c <6.5%, 2009 to 2012

2009 2010 2011 2012Johor 14.0 18.3 14.4 17.5Kedah 8.5 12.8 12.3 15.8Kelantan 8.7 9.2 12.5 11.3Melaka 18.4 15.3 16.9 21.7Negeri Sembilan 13.9 19.6 17.8 19.7Pahang 13.4 19.9 13.4 15.1Perak 14.5 16.3 13.9 18.1Perlis 30.6 24.3 26.1 27.9Pulau Pinang 12.3 18.5 19.3 16.5Sabah 22.6 19.6 25.9 28.5Sarawak 7.8 3.6 6.4 7.0Selangor 15.8 25.2 15.1 18.4Terengganu 19.9 20.5 17.9 16.2WP Kuala Lumpur 12.6 27.9 17.9 24.3WP Labuan n.a. 30.8 23.1 53.5WP Putrajaya 15.6 26.2 15.1 29.6Malaysia 13.3 17.2 15.6 18.1

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Diabetes Clinical Audit (2012)

Variable Targets Total no. of tests

Meeting target (%) Mean 95% CI

HbA1c < 6.5 % 99,823 23.7 8.1 8.1 - 8.1

BP : Systolic < 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 - 5.2TG ≤ 1.7 mmol/l 101,008 60.6 1.8 1.8 - 1.8HDL ≥ 1.1 mmol/l 76,214 65.5 1.3 1.3 - 1.3LDL ≤ 2.6 mmol/l 75,734 37.8 3.1 3.1 - 3.1BMI < 23 kg/m2 108,559 16.6 27.4 27.3 - 27.4Waist circumference

< 90 cm (Male) 35,520 33.6 94.0 93.9 - 94.1< 80 cm (Female) 55,493 14.4 90.7 90.6 - 90.8

Total: 130,340 Patients

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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%

Diabetes Clinical Audit (2009-2012)

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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 non-

alcoholic drinks to children (with NIH).• Strengthen NCD surveillance data collection under routine paper-

based 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).

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Thank you

[email protected]

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