plenary 3-kuantan fms sesi mdg 0800 060713
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17th Family Medicine Conference | 4 to 7 July 2013 | The Zenith KuantanPlenary 3TRANSCRIPT
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BATTLE AGAINST HIV/AIDS, MALARIA & TB
ARE WE WINNING?
BY
SHAARI NGADIMAN,
MD, MPH, EIP, AM
MINISTRY OF HEALTH MALAYSIA
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HIV/AIDS kill > 20 millions 90% Malaria death in Africa TB death about 1.8 millions TB/HIV death about 0.5 million
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Evolution of the Millennium Development Goals
World leaders at the United Nations Millennium Summit held in New York in September 2000 resolved to strengthen global efforts for peace, democracy, good governance, and poverty eradication while continuing to promote the principles of human rights and human dignity.
The Millennium Declaration made a strong commitment to the right to development, to gender equality and the empowerment of women, to the eradication of the many dimensions of poverty, and to sustainable human development.
The Millennium Development Goals (MDGs) emerged as the principal means of implementing the Declaration.
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In September 2000, 189 world leaders including Malaysia adopted the Millennium Declaration which was translated into a set of eight Millennium Development Goals
The goals have been commonly accepted as framework for measuring development progress. In September 2005, the UN Summit resoundingly endorsed these MDGs.
These goals are set for the target year of 2015 with 1990 as the baseline and are summarized on issues that afflict developing countries like ours.
Evolution of the Millennium Development Goals
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Millennium Development Goals 8 goals
MDG 1 - to eradicate extreme poverty and hunger.
MDG 2 - to ensure all boys and girls complete a full course of primary schooling, in other words universal primary education.
MDG 3 - relates to the status of women, by promoting gender equality and empowerment of women.
MDG 4 - to reduce child mortality.
MDG 5 - to improve maternal health.
MDG 6 - to combat HIV/AIDS, malaria and other diseases.
MDG 7 - to ensure environmental sustainability, and the measures relate to safe drinking water and slum dwellers.
MDG 8 - to develop a global partnership for development. Many of these relate to trade and financing systems that will benefit countries those saddled with debts.
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TARGETS AND INDICATORS
MDG Target Indicators
6a Have halted by 2015
and begun to reverse the
spread of HIV/AIDS
Prevalence among 15 24 years Condom use at last high risk sex Proportion with comprehensive correct
knowledge
Ratio of school attendance of orphans
6b Achieve universal access
to treatment for
HIV/AIDS for all who
need it by 2010
Proportion of infected persons (advanced HIV) with access to ART
6c Have halted and begun
to reverse the incidence
of malaria and other
major diseases by 2015
Incidence and death rates Insecticide-treated bed nets Appropriate anti-malarial drugs (fever) TB incidence, prevalence and death rates Detection and cure rates (DOTS)
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BATTLE AGAINST HIV/AIDS, MALARIA & TB
ARE WE WINNING?
PART 1
HIV / AIDS
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SYNOPSIS GLOBAL SITUATION
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SYNOPSIS GLOBAL SITUATION
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SYNOPSIS GLOBAL SITUATION
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SYNOPSIS GLOBAL SITUATION
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Target of NSP on AIDS 2011-15
80% MARPs reached prevention programmes
60% of MARPs use condoms consistently.
60% of IDUs use clean injecting equipment.
Able to eliminate vertical HIV transmission
80% ARV coverage for eligible PLHIV,
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HIV NOTIFICATION IN MALAYSIA
0
0.5
1
1.5
2
0
500,000
1,000,000
1,500,000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Detec
tion r
ate (%
)
No. sc
reenin
g
Year
No. screening Detection Rate
Cumulative HIV = 98,279
Cumulative deaths = 15,688
PLHIV (end of 2012) = 82,591
Annual Notification of HIV/AIDS and HIV&AIDS Death , Malaysia 1986 - 2012
No. of Annual HIV Testing and Positive Rate
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NEW HIV CASE: TARGET FOR 2015
YEAR
2008 2009 2010 2011 2012 2013 2014 2015
TARGET 16.0 15.3 14.6 13.9 13.2 12.5 11.7 11.0
ACHIEVED 13.3 10.8 12.8 12.2 11.7
Target : To reduce new HIV from 21.7 per 100.000 pop (year 2000) to 11 per 100,000 pop by year 2015
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TB-HIV CO-INFECTION IN MALAYSIA
Isoniazid Prophylaxis Therapy in 2010
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MALAYSIA HIV SITUATION
0
10
20
30
40
50
60
70
80
90
100
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012
Perc
en
tag
e o
f H
IV c
ases
IDU Sexual
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MALAYSIA HIV SITUATION
Estimated Prevalence of Selected Groups EPP Model 2013
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COVERED (2012):
PROGRAMME:
(REGISTERED CLIENTS)
NSEP (55,255) MMT (27,756)
Retention Rate 70.1 (2012)
PRIVATE GPs
DST (22,000)
Estimated PWID : 170,000 Coverage about : 62%
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CUMMULATIVE ON HAART AS 31 DEC 2012
15,028 on ARV in 2012
39,000 Adult Eligible for ARV in 2012 (EPP Model)
39,000 Adult Eligible for ARV in 2012 (EPP Model)
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Expenditure 2008 2012
0
10000000
20000000
30000000
40000000
50000000
60000000
2008 2009 2010 2011 2012
Global Fund
Domestic
ARV : 2011 USD 16.10 mil 2012 USD 20.41 mil
USD 16.76 1st Line ARV USD 3.65 2nd Line ARV
Expenditu
re (
US
D)
DOMESTIC FUND FOR HIV WORKS
38%
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BATTLE AGAINST HIV/AIDS
ARE WE WINNING?
YES , WE ARE ON TRACK!
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BATTLE AGAINST HIV/AIDS, MALARIA & TB
ARE WE WINNING?
PART 2
MALARIA
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6c: HAVE HALTED AND BEGUN TO REVERSE THE INCIDENCE
OF MALARIA AND OTHER MAJOR DISEASES BY 2015
MALARIA Have achieved target of halting and reversing the incidence of malaria
Can we really win the fight against malaria? In the past ten years, increased investment in malaria prevention and control has saved more than a million lives,
This is a tremendous achievement. But we are still far from achieving universal access to life-saving malaria interventions.
Until countries are able to test, treat, and report every malaria case, we will never defeat this disease,
"We need strong and sustained political commitment from all
countries where malaria is endemic, and from the global health
community, to see this fight through to the end.
Dr Margaret Chan, WHO Director-General.
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GLOBAL MALARIA
Malaria is a life-threatening disease
caused by parasites that are
transmitted to people through the
bites of infected mosquitoes.
In 2010, there were about 219 million
cases of malaria and an estimated
660 000 deaths globally.
Approximately half of the world's population is at risk
of malaria. Most malaria cases and deaths occur in sub-
Saharan Africa.
In 2011, 99 countries and territories had ongoing
malaria transmission.
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24
3,8
70
18
1,4
95
15
1,8
22
87
,43
2
44
,22
6
49
,52
6
48
,00
7
41
,70
8
55
,06
8
69
,12
7
50
,50
0
39
,18
9
36
,85
3
39
,89
0
58
,95
8
59
,20
8
51
,92
1
26
,64
9
13
,49
1
11
,10
6
12
,70
5
12
,78
0
11
,01
9
6,3
38
6,1
54
5,5
69
5,2
94
5,4
56
7,3
90
7,0
10
6,6
50
5,3
06
4,7
25
0
50,000
100,000
150,000
200,000
250,000
300,000
MALARIA IN MALAYSIA
1961 Malaria Eradication Programme (Sabah & Sarawak)
1967 Malaria Eradication Programme (Peninsular Malaysia)
1980 Malaria Control Programme
2011 National Strategic Plan for Elimination of Malaria (2011-2020)
In 1961, there were 243,870 malaria cases reported in Malaysia while in 1990, the cases have declined to 50,500.
A decade later, in the year 2000, the number of reported cases have further decreased to 12,705 cases.
In 2012, there were 4,725 cases which is a 63% reduction compared to 2000.
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6c: HAVE HALTED AND BEGUN TO REVERSE THE INCIDENCE
OF MALARIA AND OTHER MAJOR DISEASES BY 2015
MALARIA Have achieved target of halting and reversing the incidence of malaria
Malaysia has achieved the MDG goal for malaria well ahead of the 2015 deadline and has built on these achievements to strengthen current efforts and secure further commitments towards elimination by 2020 which is the target for Malaysias MDG-Plus.
The incidence of malaria has declined from 289.5 per 100,000 populations in 1990 to 54.6 per 100,000 populations by year 2000 and to 16.4 per 100,000 populations in 2012. (Target to reduce to 27.3 per 100,000 by 2015 but achieved much earlier)
There has also been a reduction in the number of malaria deaths from 43 in 1990 to 35 in 2000 and to 16 deaths in 2012. The mortality rate due to malaria has been around 0.1 per 100,000 population since 2006.
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MALAYSIA: NSP MALARIA, MALARIA
ELIMINATION 2011 - 2020
STRATEGY
1. Early case detection & prompt treatment
2. Close monitoring of imported cases
3. Residual spraying
4. Usage of bednets
5. Environmental management & anti larva.
6. Monitoring of drug resistance
7.Collaboration with the neighbouring countries
2011 - 2015 2011 - 2017
GENERAL OBJECTIVE
o To ensure Malaysia is free from local malaria transmission by 2020
SPECIFIC OBJECTIVES
o Peninsular Malaysia malaria free by 2015
o Sabah & Sarawak malaria free by 2017
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CHALLENGES
Malaria transmission in Sabah and Sarawak.
Malaria transmission among migrant workers.
Ensuring effective and efficient malaria prevention and control measures.
Inaccessible remote areas especially in Sabah and Sarawak
Zoonotic infection (Plasmodium knowlesi)
Control activities at the border areas
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BATTLE AGAINST MALARIA
ARE WE WINNING?
YES , WE ALREADY WIN THE GAME!
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BATTLE AGAINST HIV/AIDS, MALARIA & TB
ARE WE WINNING?
PART 3
TUBERCULOSIS
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Myanmar
Thailand
Cambodia
Viet Nam
Philippines
Indonesia
Indonesia
Sabah
SarawakJohorKL
Pinang
MANAGING TB SITUATION IN MALAYSIA
The National Tuberculosis Control Programme (NTBCP) in Malaysia was launched in 1961 as a vertical programme with the main aim to control and reduce the prevalence of tuberculosis as a public health concern. BCG Vaccination program was introduced as one of the strategies of NTBCP in the same year. In 1995, the programme was integrated into the general medical and health system following WHOs recommendation and implementation of primary care concept in Malaysia. Ministry of Health is the leading agency in NTBCP and collaborates with other ministries and relevant non governmental agency for this course.
Malaysia is classified as a country with an intermediate TB burden, that is, with an incidence of between 20-100 reported cases per 100,000 population annually.
Since the implementation of national TB Control Program in 1961, the number of reported TB cases had successfully reduced to from 350 cases per 100,00 to less than 100 per 100,000 in 1980s. However, since then reported TB cases has remained unchanged between 60 to 68 per 100,000 population. It was noted that the reported TB cases had show slight increment since 2004.
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Tuberculosis in the World
Incidence: 9.5 million new cases/year
Prevalence: 14 million cases
95% of cases in resource poor settings
1.1 millions co-infection TB/ HIV
(12% HIV Positive have TB)
1.7 millions deaths/year
98% deaths in poor resource countries
WHO 2010
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Incidence Rate and Mortality Rate Of Communicable Disease 2012
(per 100,000 population) Communicable Disease Incidence Rate Mortality Rate
Food and Water Borne Disease
Cholera 0.96 0.003
Dysentry 0.29 0.000
Food Poisoning 44.93 0.003
Typhoid 0.75 0.003
Hepatitis A 1.58 0.000
Vector Borne Disease
Dengue 72.20 0.000
Dengue Haemorrhagic Fever 2.45 0.119
Malaria 16.11 0.050
Typhus 0.03 0.000
Plague 0.00 0.000
Yellow Fever 0.00 0.000
Vaccine Preventable Disease
Acute Poliomyelitis 0.00 0.000
Diphtheria 0.00 0.000
Measles 6.39 0.000
Other Tetanus 0.08 0.010
Neonatal Tetanus 0.02 0.004
Hepatitis B 8.99 0.070
Whooping Cough 0.76 0.010
Sexually Transmitted Disease
Chancroid 0.00 0.000
Gonorrhoea 5.09 0.000
Syphilis 5.70 0.003
Other Infectious Disease
HIV 11.72 0.570
AIDS 4.64 1.820
Ebola 0.00 0.000
Hepatitis C 5.91 0.109
Hand, Foot & Mouth Diseases 117.67 0.003
Leprosy 1.10 0.000
Other Specified Viral Hepatitis 0.26 0.000
Rabies 0.00 0.000
Relapsing Fever 0.00 0.000
Tuberculosis 77.41 4.900
Viral Encephalitis 0.08 0.006
H1N1 0.93 0.010
Leptospirosis 12.49 0.164
Influenza 2.90 0.024
Source: Disease Control division, MOH
18 304 new TB cases (mean ~ 50 cases /day)
1414 TB death (mean ~ 4 death/day)
Source: Disease Control
Division, Ministry of Health,
2012
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Incidence Rate (Notification Rate) of TB in
Malaysia, 1990-2012
127
95
82 81 78
61 65 68
72 77
0
20
40
60
80
100
120
140
Rate/100,000
Year
WHO Estimated Incidence R per 100,000 1990-2020Malaysia Reported Incidence Rate (Notification Rate) per 100,000, 1990-2012
1. Not achieving WHO estimated incidence case
2. WHO Estimation Notification Rate (NR) downwards trend 3. Actual NR increasing (CDR 2011: 85%, 2012 :95%)
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Malaysia: TB Mortality Rate, 1990-2012
Year
26.0
13.0
8.5 8.2 7.9 7.1
4.2 4.4 5.6 5.5 5.5 5.8 4.9
0.0
5.0
10.0
15.0
20.0
25.0
30.0
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
20
18
20
19
20
20
Rate/100,000
WHO Estimated Mortality Rate (Excluding TBHIV Mortality) per 100,000, 1990-2020
Malaysia Reported TB Mortality per 100,000, 1990-2012
a
1. WHO estimated mortality rate (MR) is excluding TBHIV mortality
2. Actual MR : 1990-2011 including TBHIV mortality; 2012 excluding TBHIV mortality.
3. WHO estimated MR downward trend 4. Actual MR : plateau since 1990
Year
-
050
100
150
200
250
1990 1995 2000 2005 2010 2015
Prevalence
0
5
10
15
20
25
30
1990 1995 2000 2005 2010 2015
Mortality
Ca
ses p
er
10
0,0
00 p
opu
lation
Death
s p
er
100,0
00 p
opula
tion
TB prevalence and mortality, Malaysia
Target = 113 Target = 13
107 8.5
227 26
-
2005 2006 2007 2008 2009 2010 2011
Not evaluated 12 42 15 9 8 7 8
Failed 0 0 0 0 0 0 0
Defaulted 10 3 5 4 4 4 4
Died 8 6 8 8 9 9 9
Complete 1 3 5 1 1 1 1
Cure 69 46 67 78 78 79 78
0
20
40
60
80
100%
Treatment Outcome New Smear Positive Cases, Cohort 2005-2011
Cure Rate shows improvement . Management of TB patient need to strengthen especially on
detection of default cases and on decreasing deaths during TB treatment (TBHIV).
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Treatment Outcome New Smear Positive
Cases, Cohort 2005-2011
2005 2006 2007 2008 2009 2010 2011
Not evaluated 12 42 15 9 8 7 8
Failed 0 0 0 0 0 0 0
Defaulted 10 3 5 4 4 4 4
Died 8 6 8 8 9 9 9
Complete 1 3 5 1 1 1 1
Cure 69 46 67 78 78 79 78
0
20
40
60
80
100%
Treatment Outcome New Smear Positive Cases, Cohort 2005-2011
Cure Rate shows improvement . Management of TB patient need to strengthen especially
on detection of default cases and on decreasing deaths during TB treatment (TBHIV).
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Cure Rate States in Malaysia, Cohort 2010,2011 & 2012
Target 85%
0 15 30 45 60 75
Perlis
Kedah
P.Pinang
Perak
Selangor
WP(KL)
N.Sembilan
Melaka
Johor
Pahang
Terengganu
Kelantan
WP(Labuan)
Sabah
Sarawak
MALAYSIA
Cohort 2011 Cohort 2010 Cohort 2009
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TB control in Malaysia: 1995-2015 Special Project (2000 2010)
2000 2005 1995 2010
Impact targets
Intermediate targets
70% Case Detection
85% Treatment success
100% DOTS Coverage
TB Control
integrated to
Public Health
2015
MDG
Reverse
Policies
Notification of TB under CDC Act 1988
National Tuberculosis Information System (TBIS 2002)
Practice Guidelines For The Control
And management of TB 2nd edition 2002
BCG
Guidelines on TB in Prison
Guidelines on TB in Rehabilitation Centre
Direct Smear Microscopy 2000
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MALAYSIA NSP TO CONTROL TB
Malaysia National Strategic Plan 2011-2015
Vision
To reduce the burden of TB
Goal
To accelerate the reduction of TB related
morbidity and mortality towards the
achievement of the TB related MDG
targets by 2015.
NSP To Control TB
2011-2015
Strategies
3. Delivering, enhancing and
expanding high-quality TB treatment
4. Empower people with TB
and the community
5. Limiting people from
contracting TB
6. Promote TB centered research
1.Strengthening components of health system
2. Enhancing case detection of
TB
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*HCW
98
Migrant
127
Elderly
132
*DM
351
Close Contact
708
Prisoner
752
Drug Rehabilitation Inmates
937
HIV positive
1782
TB
Burden
in
General
Population :
77 per 100,000
*HCW- Health Care Worker
*DM-Diabetes Mellitus
High Risk Groups
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6c: HAVE HALTED AND BEGUN TO REVERSE THE INCIDENCE
OF MALARIA AND OTHER MAJOR DISEASES BY 2015
TUBERCULOSIS Have achieved target of halting and reversing the incidence of
tuberculosis
Have not achieved target of halting and reversing the incidence of tuberculosis. Unlikely to
achieve by 2015
127
95
82 81 78
61 65 68 72
77
0
20
40
60
80
100
120
140
Rate/100,000
Year
Estimation by WHO
Actual Incidence
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BATTLE AGAINST TUBERCULOSIS
ARE WE WINNING?
NOT YET!, NEED INNOVATIVE AND
VIGOROUS APPROACH TO WIN THE GAME!
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