Status of

MALARIA CONTROL
in Malaysia
by
DR. MARZUKHI MD. ISA
DEPUTY DIRECTOR DISEASE CONTROL
(Vector Borne Diseases)
DISEASE CONTROL DIVISION
MINISTRY OF HEALTH, MALAYSIA

June 2004
Scope of Presentation
Current Status of malaria in Malaysia
Areas of Concern
Sarawak
Sabah
Pahang
Drug Resistance Study
Future Interventions
Conclusion
INTERVENTIONAL MILESTONES IN
MALARIA CONTROL
2002
Increase bednets coverage and strengthen
malaria surveillance in Sarawak, Pahang and
Sabah,

2003
-Intensify case detection and vector control in
Orang Asli areas,
-Intensify malaria surveillance in urban areas
and malaria prone areas,
 Cases

100000
150000
200000
250000
300000

0
50000
19
61
243870
19
70 181495
151822
19
80 87432
44226
19
86 49526
48007
19
88 41708
55068
19
90 69127
54831
19
92 43545
36853
19
39890

YEAR
94
58958
19
96 59208
51921
19
98 26649
13491
20
00 11106
12705
20
02 12780

20 11019
Malaria Burden in Malaysia 1961-2003

04
6338
872
 Cases

100000
150000
200000
250000
300000

0
50000
1961
1965
1970
1975
1980
Implementation of DBIA '75
1985 throughout Malaysia
1986
1987
1988
1989 Adoption of Primary Health Care
Approach in malaria control
1990
1991
1992
1993
1994 Implementation of insecticide treated
bednets for malaria control
1995 Implementation of 5 year Action Plan
for Malaria Control in Sabah
1996
Policy change of chemical insecticide
1997 from DDT to pyrethroids
1998
1999
2000
Establishment of international
IMPACT OF INTERVENTIONS IN

2001
training centre for Transfer of Training
2002 Technology Course
MALARIA CONTROL FROM 1961 2003

11019
2003
6338
2004
872
 IR and CFR 1961 - 2003
35 0.4

30.2 29.7 0.35 0.35 0.35

30
0.32
0.3
25 24.5
23.9
Incidence Rate per 10,000

0.25
20.9 0.24

Case Fatality Rate

20
19.3
0.2 0.2

15 0.19
0.15
12.3
10
0.1 0.1

0.07
0.09 6.1
5 0.06 4.9 5.5 5.3
0.05 0.05 4.52 0.05
0.04
2.8

0 0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

I.R C.F.R
 No. of Malaria cases by Age Group in Malaysia

Future Intervention (2004)

1992

Improving of bed nets coverage among Orang

1993
2,000 1994

Asli in Peninsular Malaysia. 1,000

1995
1996
Thousands

20 Improving coverage in the interior of Peninsular 1997

Y-Axis

1998
0
10 Malaysia 1999
2000
0 Improving of Coverage of bed nets in Sarawak 2001
2002
Special projects carried under National MMFO in 2003
<1 tahun
1-4
5-9

2004
2003-4 projects implemented and continous
10-14
15-19
20-24
25-29
30-34

monitoring-twice/year
35-39
40-44
45-49
50-54
55-59

Age Groups
Malaria Cases by Age Group, 2003

800
700 Sarawak
Sabah
600
Pen. Malaysia
500
400
300
200
100
0
'< 5-9 15-19 25-29 35-39 45-49 >55
1year year year year year year years
CRITERIA FOR MALARIA STRATIFICATIONS

No indigenous cases within 3 years

Annual Parasite Incidence (API) less than
0.1/1000
Annual Blood Examination Rate (ABER) more
than 10%
Absence of malaria vectors
Matured surveillance system
Availability and accessibility of Health Clinics
 MAP OF MALARIA STRATIFIED
AREAS IN MALAYSIA 2001
A THAILAND U

2 SABAH
B I

AR
E NE
RANAU

P
U

PA
PULAU TAMBU
BR
NAN
LANGKAWI
KENI
NGAU

TENOM

PULAU
PINANG C MIRI

BARAM
F SARAWAK
D

BA
U

CODE STATE H G
A PERLIS
B KEDAH PULAU
C P. PINANG TIOMAN
D PERAK
E KELANTAN J
F TERENGGANU
G PAHANG
H SELANGOR
J N. SEMBILAN
K MELAKA K
L JOHOR
L
REFERENCE
MALARIOUS
AREA > 10/10,000
MALARIA
PRONE 1 - 10/10,000
NON MALARIOUS
SINGAPORE
AREAS < 1/10,000
MALARIA STATIFICATION AREA 2003

Malarious Area ( >10 Kes/10,000 penduduk)

Malaria Prone ( 1-10 kes/10,000 penduduk)
Malaria Free ( <1 kes/10,000 penduduk)
 0
2
4
6
8
10
12

Sarawak
State,

Sabah
Pahang
Perak
2003

Johor
WP Labuan
P Pinang
Kelantan
Kedah
N Sembilan
Terengganu

Incidence Rate (/10,000)

Selangor
WP KL
Melaka
Incidence Rate/10,000 by

Perlis
MALAYSIA
 Malaria cases admitted to hospital 2003
7000
6338
6000

5000

4000

3000
2615
2000 1770
1000 850
276284
0 7 106 99 45 47 119 20 1 7
Sarawak

Perak

N Sembilan
Kelantan

Selangor
Sabah

WP Labuan

MALAYSIA
Johor

Terengganu

Perlis
Melaka
Pahang

P Pinang

total no. of cases admitted to hospital WP KL

Incidence Rate in Sarawak by
District
35

30

25

20

15

10

0
han

lu

WAK
an

Sib u
Mi ri

ng

ng
Kapit

Sarike
Bi ntu
Sri Am

Kuchi

Limba
ra

SARA
Sama

Incidence Rate (/10,000)

 0
10
20
30
40
50
60
70

Be luran
Lahad D
a tu
Kunak
Pitas
Kota Ma
rud u
Ranau
Kinabat
angan
Kudat
Tawau
Sempor
na
Penamp
ang
K Ki nab
alu

Incidence Rate (/10,000)

Papar
Tuaran
Sandak
an
Kota Be
lud
SABAH
Incidence Rate in Sabah by District
 0
5
10
15
20
25
30
35
40
45

Lipis
Jerant
ut
Raub

Pekan

Romp
in
Be ra
Kuant
an
Maran
Be nto

Incidence Rate (/10,000)

ng
Temer
l oh
C High
lands
PAHAN
G
Incidence Rate in Pahang by District
 0
2
4
6
8
10
12
14
16

Hul
u Per
ak
Kin
ta
BP
ada
ng
KK
ang
sar
Ma
nju
ng
Ker
ian
Hili
r Pe
rak
LM

Incidenc Rate (/10,000)

Sel
am
a
PT
eng
ah
PER
AK
Incidence Rate in Perak by District
 Issues in malaria control
Geographical inaccessibility
Delay in diagnosis and treatment
Delay in follow-up
Increased transmission
Mobile populations
Orang Asli, ethnic groups
Immigrants from endemic countries
Re-emergence of malaria in previously free areas
Rapid turn-over and retirement of malaria
workers
Loss of skill, knowledge
Strategies in malaria control
Extended detection and treatment of malaria in
remote areas in Sabah
Subsector offices
Integration of control operations
Border states of Malaria Triangle in Orang Asli areas
Active surveillance of foreign workers and outbreak
control
Vector control
IRS and ITN
Community involvement
Capacity building
MMFO, microscopy
Area prioritisation
Sarawak, Sabah, Pahang
National Anti-malarial Drug Response
Surveillance Programme

Started from January 2003

Rationale
First line anti-asexual have been used since 1960s (CHL)
and since late 1970s (SP)
Effective first line anti-malarials are important for clinical
cure (prevention of complication and death) and effective
control (source reduction)
To gather representative data from the whole country to
monitor the situation of resistance and to confirm the
expected trend of increasing drug resistance.
 18 sentinel sites
in 7 endemic states
State No. of sites Sites

Kedah 2 Kulim, Baling

Kelantan 1 Gua Musang

Pahang 4 Raub, Lipis, Jerantut,

Muadzam
Perak 2 Tapah, Gerik

Terengganu 1 Kemaman

Sarawak 2 Sri Aman, Serian, Lundu

Sabah 4 Telupid, Kota Marudu,

Banggi, Pitas
Criteria for inclusion
Asexual P. falciparum mono-infection
Non-severe
(severe defined as
Requiring quinine treatment
Requiring referral)
Started on first line drugs:
CHL (+ PRI) : Sarawak
SP (+ PRI) : Sabah
CHL + SP (+ PRI) : Peninsular Malaysia
Sentinel sites to submit,
on monthly basis:

The report on:

-Cases completing 28-day follow up
Failure of follow up to D28
Conversion to 2nd line drugs treatment or
referral
 Definition
Valid Recruited patient conforms to inclusion / exclusion
criteria

In-valid Recruited patient not conforming to criteria / not

given appropriate drugs and dosage

Sensitive Adequate drug response ( Complete clearance of

asexual stages until D28)

Resistant Persistent or reappearance of asexual parasitemia

before D28, or referred, or changed to quinine
treatment, or clinical deterioration
Early treatment Persistent or reappearance of asexual parasitemia
before D7
failure
Late treatment Persistent or reappearance of asexual parasitemia
after D7
failure
Inconclusive Valid cases recruited, responding to initial treatment,
but lost to follow up
 Summary of response by drugs at D28
Drug Valid Com- Incom- Adeq. Early Late Total
cases pleted plete Respons failure failure failure
D28 (%) e (%) (%) (%) (%)

CHL 93 73 20 (20.4) 40 (54.8) 18 (24.7) 15 32 (45.2)

(20.5)

SP 52 12 40 (76.9) 10 (83.3) 1 (8.3) 1 (8.3) 2 (16.7)

CHL + 164 112 52 (31.7) 77 (68.8) 16 (14.3) 19 (17.0) 35 (31.3)

SP

Total 309 197 112 127 35 (17.8) 35 (17.8) 70 (35.5)

(36.2) (64.5)
 Future Interventions (2004)
Improving of bed nets coverage among Orang Asli in
Peninsular Malaysia.
Improving coverage in the interior of Peninsular Malaysia
Drug Policy Change
Improving of Coverage of bed nets in Sarawak
Special projects carried under National MMFO in 2003-4
projects implemented and continous monitoring-twice/year
Online surveillance of malaria activities
Increase professional capacity and surveillance capability in
malaria control
2004/2005 -3rd National MMFO
 Projected Target for Malaria Control in Malaysia, 2003-2020

Future Intervention (2004)

35.00 200

30.00

Improving of bed nets coverage among Orang

Incident rate/10,000
150
Asli in Peninsular Malaysia.
25.00
BEDNETS
Estimated Target

Thousands

20.00 Improving coverage in the interior of Peninsular
15.00
Malaysia 100

Improving of Coverage of bed nets in Sarawak

10.00
Special projects carried under National MMFO in 50
5.00 2003-4 projects implemented and continous
monitoring-twice/year
0.00 0
1995* 1997* 1999* 2001* 2003* 2005* 2008* 2010* 2012 2014 2016 2018
1996* 1998* 2000* 2002* 2004* 2007* 2009* 2011 2013 2015 2017 2019

X-Axis