Lecture Notes on Public Health

Services of the Ministry of

Health Malaysia

Professor Dato’ Dr Abdul Rashid Khan

Penang Medical College

i
 Contributors

1. Dr Mohammad Mostaque Hossein Ansari

2. Dr Surajudeen Abiola Abdulrahman

3. Ms Siti Fatimah Kader Maideen

4. Dr Harith Alaa Abdul Hadi

5. Dr Gomathy Subramaniam

6. Dr Mohamed Iqbal Mohamed Hamzah

7. Dr Yusoff Hasim

8. Dr Rafidah Md Noor

9. Dr Rokiah Mohd

10. Dr Jasbeer Singh

11. Dr Azizah Ab Manan

12. Pn Ku Nafishah Ku Ariffin

13. Pn Siti Rohana Din

12. Prof Rahmah Mohd Amin

13. Dr Janizah Abd Ghani

14. Dr Asmah Razali

ii
 Table of contents

Chapter Title Page

Chapter 1 Introduction 1

Chapter 2 Primary Health Care 9

Chapter 3 School Programmes 36

Chapter 4 Pejabat Kesihatan Daerah (District Health Office) 46

Chapter 5 Maternal Child Health 58

Chapter 6 Disease Prevention and Control 88

Chapter 7 Selected CDC Programmes 111

Chapter 8 Vector Borne Disease Control 170

Chapter 9 Non Communicable Disease 229

Chapter 10 Food Safety and Quality Control 256

Chapter 11 Nutritional Programmes 279

Chapter 12 Occupational Health 291

Chapter 13 Water Supply and Environmental Sanitation 311

References 332

iii
 CHAPTER 1: INTRODUCTION

Malaysia, a multi-ethnic, multicultural, and multi religious society, has a parliamentary

constitutional monarchy, with a federal government structure. The present nation of Malaysia
constitutes Peninsular Malaysia which received its independence from colonial rule in 1957,
and Sarawak and Sabah which joined the federation in 1963. The administration of the
Malaysian government is divided into three tiers; federal, state and local. Health is mainly
under the jurisdiction of the federal government, however, the state government also provide
certain public health services. Certain public health services are a shared responsibility of the
federal and state governments.

The government of Malaysia plans its health services to continuously improve the health
status of its citizens by promoting health, preventing disease and de-emphasising curative and
rehabilitative services. Although Malaysia is a developing country with limited resources,
Malaysia has an internationally recognized health care system which is equitable and
affordable compared to most other developing countries in the region and around the world.
The Malaysian health system has received appreciations from leading global health agencies
and is often referred to as a model for other developing countries. According to the WHO
ranking of health systems in 2000, (based on overall level and distribution of health in the
populations, and the responsiveness and financing of health care services), Malaysia ranked
49 out of 191 countries with a per capita expenditure of 93. By 2013, health expenditure per
capita (sum of public and private health expenditure (in Public Private Partnership,
International $) divided by population) had risen to 423. Malaysians enjoy a relatively high
standard of health care due to good accessibility to a comprehensive network of facilities.
These health facilities range from highly specialised facilities located in major urban areas to
a very effective and accessible rural health facility. Manpower is the most important asset of
the ministry of health Malaysia. Healthcare services are provided by a number of categories
of healthcare professionals at various levels of care, ranging from specialist in hospitals to
community nurses in rural clinics.

1
However this was not always the case. At the time of independence the health indicators of
the new nation was not as glossy as it is presently. Because Malaysia’s colonial masters were
looting the recourses of the nation, they were very interested in ensuring that the British
interests were not affected. This meant that they ensured that their workforce, especially the
rubber tappers and those working in tin mines, were healthy. Tin was actively mined in Perak
because of the large tin deposits in the state. Hence, it is not surprising that the first hospital
in the colony was Taiping hospital, which was built in 1880. Similarly hospitals were built in
places where European officers and their families were settled. By the time the nation
received its independence there were 65 hospitals in the newly formed independent nation.
Besides hospitals, Institute of Medical Research, entomology unit and malarial advisory
council, food safety, biochemical and pathology units were also established.

The health delivery system in Malaysia evolved gradually and systematically and was based
on the needs of the community by ensuring that the basic health services were available,
accessible, and affordable to all. In the 1960’s and 1970’s, maternal and child health which
was the major component of the basic health care of the rural health service programme, was
developed. This service provided the basic care to the rural population. In the 1970’s Applied
Food and Nutrition Programme, School Health Programme, and family planning was
integrated into the maternal child health (MCH) services. Subsequently from the 1980’s the
health delivery system was upgraded to include and expand of the scope of; maternal and
child health services by developing specific strategies to reduce maternal mortality, human
resources, infrastructure, increase accessibility to remote areas and developing the Health
Management Information System and Quality Assurance programmes.

Although the health care service in Malaysia is provided by various health care providers, the
Ministry of Health is the primary provider, planner and organizer of medical, and health
services for the nation. Besides the ministry of health, there are many other ministries’ that
provide health services such as the Ministry of Higher Education, Ministry of Defence,
Ministry of Social Welfare, local Governments etc. Private clinics cater mostly to self-paying
public and the service is particularly strong in the urban areas whereas ministry of health is
the main healthcare provider through its extensive network of primary care clinics in the
rural. Patients’ access the ministry of health primary health care clinics which acts as the
point of first contact directly as walk in patients and are referred up to higher levels when
needed. Patients utilizing the public healthcare pay a nominal fee for the services because

2
public healthcare is heavily subsided by the government. Poorer rural population utilise more
of the subsidized government health services.

The public health services are an integral and important component of the services provided
by the ministry of health Malaysia. The public health services range from health promotion,
illness prevention as well as curative and rehabilitative care. The Malaysian health system is
planned through 5 year plans in accordance to the national 5 year plans. The last 10th
Malaysia plan in 2011, the government planned to transform the health care delivery system
by increasing the quality, capacity and coverage of the healthcare infrastructure; shifting
towards wellness and disease prevention, rather than treatment and increasing the quality of
human resource for health.

Although the Malaysian government spends about 2 to 3% of its GDP on healthcare, which is
considerably lower than the World Health Organization recommendation that a country spend
a minimum of 5-6% of its GDP on healthcare, the World Health Organization rated the
overall performance of the Malaysian health care system as remarkably good. “Health
Adjusted Life Expectancy” (HALE) at birth and the maternal mortality rates are comparable
to that of industrialized countries. These achievements can be attributed to the substantial
proportion of the budget being allocated to improve rural health services, especially maternal
and child health services by increasing access to basic child health care and by the upgrade of
public health nurses and midwives to the community nurse and due to the efficient network
of rural health centres and clinics, district hospitals and general hospitals.

Malaysia’s well-developed primary health care system along with improved access to clean
water and sanitation, immunization, better child nutrition, reduction of poverty, increase
literacy especially among women and better and modern health infrastructure has improved
the health indicators of the nation. The maternal mortality rates have dropped exponentially.
This is due to the governments success in tackling poverty in addition to the strategies put in
place to improve maternal health services, upgrade of essential obstetric care in district
hospitals, improvement in the efficiency of referral systems, increase in the professional skills
of trained delivery attendants, implementation of an effective monitoring system and the
ministry’s close work with communities to remove social and cultural constraints and
increase acceptability to modern maternal health services. Government was cognizant of the
fact that pregnancy and delivery were influenced by traditional and socio-cultural practices,

3
beliefs, and taboos. Extensive efforts were made in health education in clinics, at home, in the
villages, and among influential persons in the community to improve ‘acceptability’ of
modern health services. In the 1960s and 1970s the Ministry of health began to register and
train traditional birth attendants against practising harmful traditional practices. The
traditional births attendants were also taught to recognize complications of pregnancy and to
encourage mothers to follow up in health clinics. They were, however, allowed to carry on
harmless traditional practices, such as reciting prayers and postnatal massage. Almost all
births in Peninsular Malaysia are now attended by skilled health personnel.
The Malaysian life expectancy at birth (for both sexes), infant mortality and under - 5 years
mortality rates are comparable with the most developed nations. The infant mortality rates
and under-five mortality rate declined to 6.3 per 1000 live births in 2008 and 7.6 per 1000
live births in 2006 respectively. The life expectancy at birth for both genders has increased
significantly over the years. In 1957 the life expectancy at birth was 56 years for males and
58 for females, this had improved to 71.7 years and 76.5 years respectively in year 2007.

90

80 78.4

70 68.9

60

50 48.5
Neonatal Mortality Rate
Infant Mortality Rate
40 39.4
Toddler Mortality Rate
32.2
30 29.5 30.1
25 23.8
20 21.4
19.3
16.4
14.2 13.1
10 11.1 10.4 10.3
8 8.5 6.86.8
5.8 6.5 6.6
4.2 3.1 3.7 3.9 4.4
2.1
0.9 1.4
0.8 0.6
0 0.5 0.4
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010

4
 Life Expantancy at Birth
90

80
76.2 77
73.5 74.3 74.7
70.5 72.4 71.4 71.9
70 68.7 68.9 69.5 70
66 66.4 67.7
65.6 64.3
63.1 61.6
60

50
Male
40
Female
30

20

10

0
1966 1970 1975 1980 1985 1990 1995 2000 2005 2010

Due to the efforts of the ministry of health in its prevention and control programmes there
have been downward trends in Hepatitis B, measles, diphtheria, neonatal tetanus, pertussis
and HIV. The rates of vaccine preventable diseases have dropped in recent years due to the
government’s active vaccination programs leading to high rates of immunization coverage.
Infectious diseases especially dysentery has been successfully controlled through public
health measures. Malaysia has also virtually eliminated malaria from urban and other densely
populated areas. Malaysia was certified as polio-free country by the World Health
Organization on 29 October 2000.

Mission and Vision of Health of the Ministry of Health Malaysia

The vision and mission of the Ministry of Health Malaysia as stated in its website is:
“Malaysia is to be a nation of healthy individuals, families, and communities, through a
health system that is equitable, affordable, efficient, technologically appropriate,
environmentally adaptable and consumer-friendly, with emphasis on quality, innovation
health promotion and respect for human dignity, and which promotes individual
responsibility and community participation towards an enhanced quality of life”.

5
And the mission of the ministry is to lead and work in partnership
I. to facilitate and support the people to
• attain fully their potential in health
• appreciate health as a valuable asset
• take individual responsibility and positive action for their health
II. to ensure a high quality health system that is
• equitable
• affordable
• efficient
• technologically appropriate
• environmentally adaptable
• customer centred
• innovative

III. with emphasis on

 professionalism, caring and teamwork value
 respect for human dignity

 community participation

The management of health and medical services by the ministry of health Malaysia is
decentralized to the regions, states and districts.

The figures below shows the organization chart of the state health and district health
department respectively

State Health
Director

Medical Food Safety

Management Public Heath Dental Pharmacy
Services & Quality

Organization chart at state health level

6
 District Health
Officer

Family Health Administration Disease Control

Disease Food safety & Control

Maternal &
Primary Care Surveillance BAKAS
Child Health
KMAM

Organization chart at the district health department

The table below shows the main Public health functions at the state and district health level
Family Epidemiology Engineering Public Health Health Food
Development Enforcement Promotion Safety &
Quality

Primary Care Comm. Disease Environmental CDC Act Focusing Domestic

Control Health sanitation Healthy Life
style

Family Vector Borne Drinking Water DDBIA Trade

Development Diseases Quality (export &
import)

Wellness clinic Non Food Act Food

Communicable Standard
Diseases
Nutrition Occupational and Food Lab
Environmental
Health

Table showing the Main Public health functions at the state and district health level

7
The table below shows the main and subcomponents of the health services at the district
health department
Component Sub Component
Family health MCH
Nutrition.
Disease control CDC
NCDC
Food quality control Food sampling.
Premise inspection.
Issuance of cert. for food export.
Enforcement.
BAKAS Safe water supply.
Sanitation.
Solid waste.
Drainage.
Vector borne disease Dengue, Filariasis and malaria
KPAS Environmental
Occupational health

National Health and Morbidity Survey

A number of references are made to the national Health and Morbidity Survey in these notes.
The National Health and Morbidity Surveys (NHMS) are community based surveys
conducted 10 years apart. These surveys are conducted to gauge the extent of disparity in
health status and enhance an understanding on the health seeking behaviours of the
Malaysian population. The NHMS I was conducted for Peninsular Malaysia, leaving out the
states of Sabah and Sarawak, which are situated in the island of Borneo. The NHMS II & III
was conducted throughout the country. The last NHMS (III) was conducted in 2006.
Population and housing census of family is also conducted every 10 years. Censuses were
conducted in 1970, 1980, 1991, 2000 and 2010.

8
 CHAPTER 2: PRIMARY HEALTH CARE

Historically public health has always been concerned with dealing with unhealthy living
conditions and health concerns related to food, water, air and infectious diseases. However,
with the realisation that the concept of health has social in addition to biological and medical
concept, it has now evolved to encompass the importance of healthy mind and body.
Similarly this public health services dealing with primary health care have also evolved to be
comprehensive and all inclusive. Studies have shown that countries with strong primary
health care services record lower rates of hospitalization, mortality and have better health
outcomes.

Primary health care, according to the declaration of Alma-Ata during the international
conference on primary health care, has been defined as “Essential health care; based on
practical, scientifically sound and socially acceptable methods and technology made
universally accessible to individuals and families in the community through their full
participation and at affordable cost by the community and country to maintain at every stage
of their development in the spirit of self-reliance and self-determination”. Because primary
health care is often the first experience of an individual with formal health care system at an
affordable cost, it can also be simply defined as “better health for all with the provision of
cost effective services close to home”.

Primary care services involve all aspects of health care including promotive, preventive,
curative and rehabilitative. The services may range from basic to specialist care located in the
community. Because primary health care is an integral, integrated, essential and universally
accessible part of the country’s health system, good primary health care services can help
reduce disease and economic burden, and assure equity by focusing on the overall social and
economic development of the community.

There are 5 basic principles of primary health care as constructed by the Alma-Ata
conference of the WHO in 1978

1. Equitable distribution - Primary health care must be made available to all individuals
equally in a community irrespective of their gender, age, caste and colour, urban, rural and
social class.

9
2. Community participation toward achievement – The participation of the people in the
community is essential. They must be engaged and involved in decision making because
without community participation the proposed policies will fail irrespective of how effective
or how rigorous the enforcement is. Emphasis is placed on health education and literacy.
Communication for behavioural impact (COMBI) is an ideal example of community
participation.

3. Manpower development – A consistent number of sufficiently trained health care workers

must be made available for programs and interventions.

4. Technology – Technology which is affordable, accessible, feasible and culturally

acceptable to the community is imperative e.g. the use of refrigerators for vaccine, use of
ORS for diarrhoea etc.

5. Multi-sectional approach- It is important to understand that maintenance of good health is

a product of the involvement many other sectors besides the conventional health providers. A
good example would be the close working relationship of the ministry of health with the
welfare department in providing services for children with special needs etc.

The essential elements of Primary Health Care involves

1. Health Education
2. Promotion of food supply and proper nutrition, an adequate supply of safe
water, and basic sanitation
3. Maternal and child health care including family planning
4. Immunization against major infectious diseases
5. Prevention and control of locally endemic diseases
6. Appropriate treatment of common diseases and injuries
7. Promotion of mental health

10
Primary Health Care (PHC) in Malaysia
History
The health status of the country’s population especially the rural folks improved after the
independence when the new Malayan government began to introduce rural health services
which were almost non-existent during the pre-independence period. The three tier health
system prior to 1973 consisted of ‘Rumah Bidan dan Klinik’ (midwife clinic) which was the
lowest health centre providing PHC services at the village level. The services provide by
these midwife clinic’s included basic care and assistance for the mothers before, during and
after the delivery of the child. Four of these midwife clinics were linked to a ‘Pusat Kesihatan
Kecil’ (health sub-centre) which was manned by medical assistants, nurses and midwives
providing health care to a population of 10,000. Four of these health sub-centres were further
linked to a main health centre called ‘Pusat Kesihatan Besar’ that served a population of
50,000 people. This 3 tier was then changed to a 2 tier system due to the advancement in
transportation, communication and extensive development of health infrastructure. The
transformation included a change in the health care structure where the midwife clinics were
upgraded to ‘klinik Desa’ (community clinics) which provided services for every 4,000
population. Each ‘Klinik Desa’ covers an area of 4.5 to 7.5km radius and managed by a
Jururawat Desa (community nurse) who acts as a frontline PHC worker providing promotive,
preventive, and curative services. Besides the MCH services, the nurses also provide basic
accident and emergency treatment and ambulatory curative treatment for simple illness.
‘Klinik Kesihatan’ (Health Clinic) replaced the ‘Pusat Kesihatan Kecil’ and the ‘Pusat
Kesihatan Besar’ and is manned by a doctor and providing services for a population of
15,000 - 20,000.

Picture of the old ‘Klinik Desa’ and the new community clinic (klinik desa)
Before 1971: After 1971

11
 Maternity health clinic (Klinik Bersalin Community Clinic
Kesihatan, KBK) (Klinik Desa )
Health sub-centre (Klinik Kesihatan Kecil)
Health clinic
Main health centre (Klinik Kesihatan Besar) (Klinik Kesihatan )
Organization of health clinic before and after 1971

Ministry of Heath Malaysia’s Primary Health Care Services

The Ministry of Health Malaysia is the main provider of primary health care services in
Malaysia. The ministry provides primary health services through a national network of
hospitals, clinics and other services to ensure that the objectives of universal access to
essential health services is attained. The fundamental principles of primary health care
according to the ministry of health Malaysia include
 Health protection and promotion, illness prevention and early detection
 Assessment, treatment and referral at the first contact point in the health system
 Community based management for people with chronic and complex conditions,
including pre-admission and post-hospital care
 Community-based health maintenance support for people with disability and frail
older people living independently in their own home
 Community-capacity building
 Information and communication technology as enabler to facilitate knowledge and
information management for quality service

The basic health services provided by the ministry of health Malaysia includes

 health education, out-patient care service, including mental health and provision of
essential drugs
 food supply and proper nutrition
 safe water and basic sanitation
 maternal and child care, including immunization and family planning
 prevention and control of endemic diseases
 dental care
 school health service and

12
  additional services with expanded scope which include geriatric health care,
adolescent health care, community mental health, occupational health, rehabilitative
services, home care nursing etc.

Family Health Services in Malaysia began in 1956 with the Maternal and Child Health
Programme in 1995 which was later expanded to form the Division of Family Health
Development Division (FHDD) which is involved in planning, implementation, monitoring
and evaluation of the activities related to family health and Primary Care health services to all
levels of the community. The main component of the FHDD includes Primary Health Care
and Family Health. Nutrition which was part of the division is now a separate division.

The aim of the services is to provide health care services from womb to tomb, using the eight
health goals as a guide

1. Wellness focus
2. Person focus
3. Informed person
4. Self-help and self-care
5. Care provided at or close to home
6. Whole and continuous care
7. Care that is tailored as much as possible
8. Effective, efficient and affordable services.

The mission of the family health division is to develop a comprehensive and integrated
family health programme for every individual, family and community by encouraging
community participation in health care through increased awareness and by establishing
rapport and collaboration with various government as well as non-governmental
organizations (NGOs) in the implementation of the family health activities.

According to the ministry of health, the specific objectives of the family health division is to
– promote and maintain the health of women in the reproductive age group and other health
conditions besides maternal and reproductive health; promote and maintain the health of
infants and children up to school going age, adolescents and young people; to promote and
maintain the health of the elderly members in the family; provide preventive, promotive,
curative and rehabilitative health services to all members of the family at the first point of

13
contact; promote and improve healthy nutrition practices and improve the nutritional status of
the community.

The maternal and child clinics provide antenatal and postnatal services, pap smear and self-
breast examination, child health including immunization, home visit for antenatal and
postnatal mothers, home delivery, defaulter tracing, family planning, health education,
counselling and school health services which provide immunization after 7 years old and
health screening.

The services in the outpatient department include basic emergency services, health screening
for various age groups mainly adolescent, elderly and adult men and women. Most of the
outpatient departments have follow up services for chronic illnesses mainly diabetes,
hypertension, asthma, infectious diseases like Tuberculosis, HIV, sexually transmitted
diseases, a structured referral system, ambulance for emergency purpose, pharmacy, a
laboratory and rehab services. There are also special services for smoking cessation
premarital and mental health.

Environmental health services include supply of clean water, systematic sullage and sewerage
system, food quality control and control of communicable disease.

Rehabilitation is an essential part of the primary health care service provided by the ministry
of health, Malaysia. The services provided include special services for children with cerebral
palsy & developmental delay, adults with stroke, osteoarthritis, rheumatoid arthritis etc.

Primary Health Care & Health Indicators

The common health indicators used by the ministry of health Malaysia to reflect the primary
health care delivery system provided and achieved by the health care delivery system include
life expectancy at birth (male/female), crude birth rate, crude death rate, infant mortality rate,
toddler mortality rate, maternal mortality rate, perinatal mortality rate and neonatal mortality
rate, population per doctor, public health facilities ratio to population, child immunization
rate. These indicators are consistently monitored by the ministry of health Malaysia to assess
the impact of the delivery system.

14
Klinik Kesihatan (Health Clinic)

Scope and Function of Health Clinic (Klinik Kesihatan) includes promotive, preventive,
curative and rehabilitative to clients who include but not limited to mother, child, adolescent,
adult and elderly. The services include wellness, illness, supportive and emergency. All
illnesses including acute, chronic and infectious diseases are a priority. Community
empowerment by information & strategic planning is a means of achieving this.

The objective of the services in the ‘Klinik Kesihatan’ is to integrate promotive, curative,
preventive and rehabilitative services under one roof and maximizing the full potential of its
staffs, resources and infrastructure by facilitating sharing of skills and continuous care and
avoiding duplicative efforts.

Services
The services provided in a ‘Klinik Kesihatan’ include
a. Non-communicable disease - diabetic screening and follow-up clinics for diabetic,
cardiovascular, asthma control and treatment, mental health etc.
b. Communicable disease - TB screening and treatment (DOTS), HIV/AIDS screening,
counselling and treatment programme, Dengue fever treatment and notification etc.
c. Screening - is routinely conducted. HIV test for pre-marital individuals (it is
mandatory for Muslims), thalassemia and colorectal cancer are examples of screening
tests conducted in the health clinics.
d. Quit smoking services clinic
e. Methadone services clinic
f. Counselling - include pre-marital and pre-pregnancy counselling.
g. Supportive services - include diagnostic, laboratory and imaging facilities, pharmacy,
and rehabilitative services.
h. Laboratory services – the investigations that can be conducted in the health clinics are
limited. Liver profile, lipid profile, Full Blood Count, Urine FEME, Urinalysis, UPT,
AFB, X-ray. Fundus Camera are the common investigations conducted in the clinics.
i. Other services - include Xray, Ultrasound and Fundus Camera Examination

15
 MCH
School
Health OPD
Services

Basic
X-ray
Labs HEALTH
Physiotherapy
SERVICES

Health
education
CDC
Oral
Health

Figure showing the basic and essential health services at Klinik Kesihatan

16
 Family Medicine
Specialist

Medical Officer i/c

pengurusan

Medical Medical Pharmacist Laboratory Administration Nurses Rehabilitation X-ray

Assistant Officer

Under the new integration program in the Klinik Kesihatan, there are no longer specific
clinics during specific days; instead there are two main clinics i.e. outpatient & maternal child
health clinics. The purpose of this is to enable patients with all sorts of illnesses to visit the
Klinik Kesihatan on any day.

Outpatient department

Health clinic (Klinik kesihatan)

Maternal and child care

Integration of outpatient department with maternal and child health

Outpatient Services

The main types of patients visiting these clinics are patients with chronic illnesses (usually
patients with appointments), ‘walk-in’ patients (usually patients with acute illnesses) and
emergency cases. Health risk assessment for walk-in patients are also conducted which
includes screening for Diabetes, Hypertension, Cholesterol, Colorectal cancer, mental health
and HIV. Follow-up services for chronic diseases mainly diabetes, hypertension, asthma, TB,
HIV, STDs, anti-smoking and adolescent are also provided. Services include follow up

17
treatment and referral services. Ambulance services for emergencies and pharmacy for
specialist and non-specialist drugs as well as lab services for urine test, blood test and others
are also available in the Klinik Kesihatan.

Patient arrives in KK

Queue counter (take system number)

Counter of registration and payment

Examination room

Laboratory

x-ray

health education

Pharmacy (medication) or patient refer to the hospital

Flow chart of outpatient clinic in Klinik Kesihatan

Maternal and Child Health Services (Perkhidmatan Kesihatan Ibu dan Anak)
According to the WHO technical report, the objective of maternal and child health services is
to ensure that every expectant and nursing mother maintains good health, learns the art of
child care, has a normal delivery and bears healthy children. The Maternal and child health
clinic in Malaysia provide services for both the mother and the child.

18
Safe motherhood
With the philosophy that every mother has the right to expect that her baby will be born
alive and healthy just as every baby has the right to a living and healthy mother, safe
motherhood initiatives programme was implemented in 1989 to reduce maternal deaths in
the country.

Pillars of safe motherhood include

 Family planning
 Antenatal care
 Obstetric care
 Postnatal care
 Post-abortion care
 STI/HIV Control

The essential services include ensuring safe motherhood included

 Intervention before and during pregnancy - Information and services for family
planning, tetanus toxoid immunization, screening, supplements nutritional advice,
STD/HIV prevention and management etc.
 During Delivery - safe and hygienic delivery, early detection and management of
complications etc.
 Intervention after delivery of new-born - resuscitation, prevent hypothermia, early
and exclusive breastfeeding
 Intervention of the mother after delivery - early detect and management of
postpartum complications, postpartum care, information and services for family
planning, STD/HIV prevention and management

The scope and function of the services include to

 promote and maintain the physical, mental, social and spiritual health of every woman
in the reproductive age groups
 provide quality and client friendly services to every pregnant woman

19
  ensure that they receive the optimal health care during pregnancy and undergo a safe
delivery process in a clean environment and have a healthy baby
 promote the health of young potential parents by helping them to develop a proper
approach to family life and community welfare and
 give guidance in the skills of being a good mother and guidance related to family
planning

A comprehensive range of services are offered in the Klinik Kesihatan Ibu Dan Anak (KKIK)
(Maternal and Child Health Clinic) which include antenatal care, delivery, postnatal care,
home visits (home visits for antenatal mothers, for home delivery, postnatal mothers, new-
born and defaulters), family planning services, child care and school health services which
include screening and providing immunization to the school children in accordance to the
national immunization programme.

Upon the first visit to the maternal health clinic, the mothers are registered and a brief
menstrual history is taken and urine pregnancy test is carried out. If the pregnancy test is
positive, booking is made and two cards are filled i.e. card A for the patient’s reference and
card B for the reference of the clinic staff. Booking visit is recommended before the 12 th
week, during which a detailed history, physical examination, and laboratory investigation is
done. Vitamins and supplements are given and health education concerning nutrition,
breastfeeding, and healthy lifestyle imparted.

First visit to the child clinic involves the registration of the child. Weight, height and physical
assessment are done and plotted against the child’s growth and developmental chart. In
addition to advice, counselling and health education, the management of illnesses and
immunization is done accordingly. A set frequency of visits is recommended.

Klinik 1Malaysia (1Malaysia Clinic)

Malaysia has successfully reduced poverty and has progressed from a predominantly rural
agricultural society in the 70’s to an industrial, knowledge-based economy. With the
extensive development of industries leading to greater opportunities for work in urban areas,
there has been a rapid rural to urban migration. The proportion of urban population increased
from about 50% in 1990, 62.0% in 2000, 65.1% in 2005 to 71.0% in 2010. Pulau Pinang

20
(91.4%) is among the states with highest level of urbanization. Because of the rapid
urbanization, the number of government and non MOH hospitals has increased and the
government had put an emphasis in building new health centres to cater to the increasing
population.

In 2010, health clinics, called “Klinik 1Malaysia” were set up in strategically located urban
residential areas to provide services to the urban poor population. These clinics provide
treatment for minor illnesses and common complaints like headaches, fever and flu etc. and
minor surgical procedures like wound dressing, removal of stitches to blood pressure
measurement and diabetic patient follow up. These ‘Klinik 1Malaysia’ are manned by
assistant medical officers and nurses and operate from 10 am to 10 pm daily. There were
about 119 clinics nationwide by the end of 2012 to provide services to the urban poor
population. The services are provided at an affordable charge of RM1 for Malaysian and RM
40 for foreigners.

Pictures showing 1Malaysia clinic

21
Special Programmes (Expanded Scope)

a. Perkhidmatan Kesihatan Warga Emas (Elderly Health Services)

Ageing which is defined as a progressive state beginning from conception and ending with
death is associated with certain physical, social and psychological changes. A country is
considered to have an ageing population when the population aged 65 years and above of a
country reaches 7% of its total population. Population of the world is ageing and Malaysia is
no exception. Although comparatively the population of Malaysia is relatively young, the
trend in the transition of age structure suggests towards an ageing population. The crude birth
rate has declined more than 34% last 30 years and there has been a decline of total fertility
rate by about 35%. The proportion of the population of Malaysia below the age of 15 years
decreased to 27.6% from 33.3% in 2000. The elderly population of Malaysia was 3.1% in
1950, and increased to 3.7% in 1980, and 5.1% in 2010. It is estimated to increase to 8.3% by
2025. However some states in the country have exceeded the 7% mark. The median age
increased from 23.6 years in 2000 to 26.2 years in 2010. The aged are living longer as
evidenced by an increase in life expectancy. With increasing age, there is decline in body
functions and activities and people usually suffer from multiple diseases or having co-
morbidities that affect their ability to recover, and making them more dependent on others. It
is estimated that about 20% of all admissions into hospitals are elderly patients. This
percentage is expected to increase which will cause in the increase in health care costs.
Studies in developed countries show that about 30 to 50% of the total healthcare spending
goes towards the care of the elderly who use health care far more than younger people
because they tend to develop chronic, expensive and often incurable diseases. The MOHM
estimates that in the future 30% to 60% of total health care cost will go towards the elderly.
According the NHMS II the five most common morbidities among them are hypertension,
diabetes, problems related to joints, respiratory system and eye problem. NHMS III showed
the disease pattern among the elderly had changed from diseases associated with ageing to
disease associated with life style i.e. hypertension, hypercholesterolemia, diabetes mellitus
and adult asthma.

22
 Population projections by Age Group

80

70 68.8 69.2 68.6 68.5 69

67.6 68.2

60

50
0-14
40
15-64

30 65+
27.4
25.4 24 23.4 22.5
20 21.1 19.6

10 10.4 11.4
8 9.3
5 5.8 6.8
0
2010 2015 2020 2025 2030 2035 2040

Dependency Ratio, Malaysia

Ratio
60

50
47.8 46.5 46
45.4 44.5 45.7 44.9
40 40.4
36.9
34.7 34 33
30 30.8
28.3

20
15.2 16.6
13.6
10 9.9 11.7
7.4 8.5

0
2010 2015 2020 2025 2030 2035 2040

Total Young Old

23
 Estimates Of Annual Per Capita Outpatient Utilisation

16

14
Annual outpatient visits per capita

12

10

1986
8
1996
6 2006
2011
4

0
<5 5-9 10-1415-1920-2425-2930-3435-4040-4445-4950-5455-5960-6465-6970-7475-7980-84 85+

Age groups (years)

With the impending ageing population, the health care system will have to plan to
accommodate the needs of older populations while continuing to address other priority health
issues like child and maternal health. The objective of the elderly health services is to
improve the health status of the elderly and encourage their participation in health promotion
and disease prevention activities by providing age friendly, affordable, equitable, accessible,
culturally acceptable, gender sensitive, seamless health care services in a holistic manner at
all levels. The specific objectives of the programme is to comprehensively plan, prepare and
monitor the health services to the elderly, create and enhance cooperation between Ministry
of Health with government and non-government agencies in planning and implementing
health services to the elderly; And to increase knowledge and community involvement
concerning elderly care problems. The indicators used to assess the programme include 100%
of Health Clinics which runs the elderly health Programme by 2015; 75% trained staff
involved in the programme by 2015; and 75% of the elderly use the services of the elderly
health program by 2015.

The functions of the elderly health services are to carry out health status examinations and
formulate follow up plan, perform health screenings for early detection of illnesses and early
treatment. The clinics also carry out health promotion activities like having weekly morning
exercise programs. Where necessary, cases are referred and house visits are made.

24
 b. Mental Health
“Without mental health there can be no true physical health” – Dr Brock Chisholm, the first
director–general of the WHO. The incidence and prognosis of mental illnesses and many
non-communicable diseases are interrelated. Diabetic patients are more likely to develop
depression and depressed diabetic patients have greater difficulty in self-care. Patients with
mental illness are twice likely to smoke. Almost half of cancer patients suffer from
depression and anxiety, and treating the symptoms can help improve survival time. The risk
of myocardial infarction is higher in depressed individuals and depression increases the risk
of death in patients with cardiac disease and treating depression in someone who had a
myocardial infarction has shown to lower mortality.

The objective of the services is to train and empower patients in carrying out their daily living
activities and skills. The services include physical health examination, mental health
promotion, screening for stress and risk factors for depression and anxiety, training skills on
coping with stress. Patients are also counselled on healthy eating habits, sleep hygiene and
cleanliness. When necessary, referral and follow up is done.

c. Kesihatan Remaja (Adolescent health)

Being a relatively a young country the government of Malaysia has made extensive
investments in health, education and sports for the young. Although a majority of adolescents
have benefitted from such services and programmes, there remain those who are especially
vulnerable and require additional support and attention.

According to the WHO, adolescents are defined as those aged between 10 to 19 years of age
and are subdivided into three categories which include early adolescents from 10-14 years,
middle adolescents from 15-17 years, and late adolescents from 18-19 years old. During
adolescence, the period of transition from childhood to adulthood, an individual may be
confused with his/her identity because he/she is neither a child nor an adult. Because
adolescence is a period of enormous energy, creativity, and resilience, it is an opportune time
to lay the foundation for a healthy future. During this stage different changes occur to their
body including physical, biological, emotional, psychological, interpersonal relationships,
and changes in responsibilities. Because it’s the last opportunity to intervene before increased

25
vulnerability to devastating social, health, and economic circumstances arises, they should be
empowered with the knowledge and understanding of the changes occurring to them
physically and emotionally. With the correct and adequate knowledge and information the
adolescent can make the right lifestyle choices and decisions that will affect their future.

The services provided include adolescent health status examination which includes height,
weight, BMI measurements, early detection of abnormalities and subsequent referrals if
needed; health counselling and promoting adolescent health to the youth, school children and
community by encouraging them to live a healthy lifestyle; and the prevention of
communicable diseases including sexually transmitted infection and drug abuse. Youth are
encouraged to get involved in youth development progammes. PROSTAR (Program Sihat
Tanpa AIDS untuk Remaja) is one such programme which was started to educate about and
reduce HIV/AIDS and other social problems including substance abuse among the
adolescents through peer role modeling and various other activities.

Program for special need children and adult

The objectives of this program is

 to provide comprehensive health care to special need group for optimum health
through integrated care including health promotion, prevention, early detection,
prompt treatment and rehabilitation.
 to educate, support and motivate the carers;
 to collaborate with other agencies in giving comprehensive care to special needs
group

Program ‘pemulihan kanak-kanak keperluan khas’ (Special needs Children Rehabilitation

Program) are centres in the community managed concurrently with the Welfare Department.
The objectives of these centres are to help children with special need to live independently
and be integrated into community by equipping them with functional skills; to detect illnesses
and treat them early; help parents register with the Welfare Department; educate, support and
motivate the carers; and to equip the children with functional skills in order to improve the
activities of daily living.

26
The activities carried out by the centres include
1. screenings and general physical examination and registration of the known cases in
the area
2. Early Intervention Programmes (EIP) with the family members
3. Counselling services for the family members
4. Carrying out rehabilitative activities with health providers
5. Compiling and updating records
6. Report preparation and presentation at regular intervals or whenever required
7. Refer cases as needed and to monitor the progression of old cases

Children born with congenital malformations such as Down syndrome, cerebral palsy,
blindness and mentally handicapped are identified and registered with the Community
Rehabilitation Program (CBR) or ‘Pemulihan Dalam Komuniti’ (PDK). Parents/guardians
and family members and community authorities and volunteers are taught how to help
children with disabilities to live independently and be integrated into community. This
program is managed by a committee appointed by the CBR. This committee is a good
example of integration between different working departments. The advisor to the CBR
Committee is the District Social Welfare Officer assisted by officers from the Ministry of
Health and Ministry of Education (Special Education).

Records and Registers Maintained In Klinik Kesihatan (Health Management

Information System (HMIS))

The records and registers are well maintained and constantly updated to provide the best level
of care to the patients to help staffs to monitor follow up or referred cases. The records and
registers are also used for the preparation of scheduled reports related to referrals of
complications of pregnancy, postpartum and disabled children. Besides this, these records
also serve as important tools in evaluating the efficiency of health care services. There are
several types of registration books and documents i.e. Mother care, Childcare records and
School health service. ‘KIB’ are records and registers for maternal health, ‘KKK’ are records
and registers for Child health, ‘KSK’ are records and registers for School Health Service.

27
The objective for the maintenance of Registration form for referrals due to complications
during pregnancy, labour and post-partum; Neonatal complications and children 28 days and
above and disabled children is to help staffs to assess the follow up pattern for referral cases.

Information regarding birth registration (dead/alive) is collected to help the operation officers
to provide continuous care for mother and child and to form the denominator to calculate the
coverage of vaccination for babies, death rate for prenatal, neonatal, infant and pregnant
mothers.
Information on house visits is collected to enable operation staffs to plan home visits and
provide follow up to all missing and special cases and as a management tool to control the
performance of house visits.

Information regarding maternal deaths and infant mortality is collected to enable research for
the maternal and toddler mortality (under 5 years old) and as a guide to prepare
statements/reports regarding deaths during labour, intrauterine deaths, prenatal deaths,
neonatal deaths and death of children between 1-4 years old.

Information regarding childcare is collected to help provide better care to children under 7
years old and as a tool to control the performance of the operation staffs. Several categories
of children are given special attention especially babies under 1 year old, children between 1-
4 years old and pre-school children between 5-6 years old.

Information regarding the attendance to the maternal and Child Health clinic is collected to
determine the rates of attendance of children between 0-1, 1-4 and 5-6 years old and
attendance of post-partum mothers to the clinic.

Information regarding vaccination given in the Child Health Clinic is collected to help staff
nurses to record vaccination provided in the child care health clinic and to enable them to
prepare statements/and reports on certain vaccinations especially coverage per area according
to age groups.

Information regarding the Pre-school and school health is collected to help follow up care for
children in pre-school/school who need help. The targeted students are pre-school children
and year 1 & 6 and form 1,3 & 5 students. The records are maintained to enable staff nurses
to record the vaccination given during pre-school/school time and help them in the
preparation of statements/reports.

28
Human Resources in Klinik Kesihatan

Family Medicine Physician

A family medicine physician @ specialist (FMS) is also known as the primary care physician.
He or she is usually the first contact for a person with an undiagnosed health concern as well
as continuing care of varied medical conditions, not limited by cause, organ system, age or
diagnosis. The FMS heads the primary care centre and is capable of treating simple and
complicated general health conditions at an outpatient setting. The FMS also plans and
executes health awareness or promotion programs as instructed by the district health office.

Pegawai Perubatan dan Kesihatan (Medical and Health Officer)

The medical and health officer reports to the Family Medicine/Clinical Specialist and is
stationed at the outpatient clinic and sees patients who come to the outpatient department and
to the maternal and child health clinics. He/she also supervisors the school health team.

The responsibilities of the medical and health officer -

1. Manage patients in the outpatient department. They see both new and follow up cases
e.g. diabetes, hypertension, thyroid disorders, anaemia for investigation, suspected
dengue cases, stable psychiatric cases for monthly medication etc. They assess
patients, adjust methadone dosage, and monitor withdrawal symptoms and substance
use for Methadone Maintenance Therapy and where necessary refer cases to hospital.
2. In the MCH clinic the doctor is responsible for the prenatal, antenatal and postnatal
cases that walk in. He/she will also see referred cases from ‘Klinik Desa’ and ‘Klinik
1Malaysia’ e.g. pregnancy induced hypertension, gestational diabetes, excessive
weight gain during pregnancy, small for gestational age. They perform ultrasound
scans for dating purposes and others at ≥ 12 weeks and ≥ 24 weeks. They also give
advice on family planning including insertion of IUD.
3. Conduct health check-up and prescribe medication to the community through the
Mother and Child Health Care service, family planning services and treatment
services and referrals
4. Conduct activities and health programmes in certain areas by giving health talk,
conducting focus group discussions, conducting home visits for problematic cases,

29
 conducting Continuous Medical Education (CME) or courses for staffs, evaluating the
activities of MCH /OPD
5. Work together with the other health units
6. Administratively the medical officer is required to conduct visits to supervise the
community clinic (klinik desa)
7. Approve or disapprove leave for the staffs under his/her care, sign birth registration
forms to approve the place of birth for selected cases and evaluate the work
performance of the staffs under his/ her care
8. Attend meetings and become members of the board for head of units meeting, basic
health development meeting, attend where necessary meetings with the
hospital/health/dentistry department
9. Attend courses / seminars for self-professional development
10. Substitute a colleague who is on leave

Penolong Pegawai Kesihatan (Assistant Medical Officer)

An assistant medical officer, previously known as, medical assistant has the responsibility to
examine, diagnose, and treat patients under the supervision of a physician, to do certain
procedures and handle emergency cases at Klinik Kesihatan. They may also run the health
clinic in the absence of a medical doctor. They also do health promotion and prevention of
illnesses, health screening and provide counselling services They also have the responsibility
of performing a wide range of administrative functions necessary for the efficient and smooth
delivery of health care delivery such as the completion of medical records and retens.

Jururawat Kesihatan (Staff Nurse)

They manage all nursing activities related to family medicine. Besides this they are also
involved in communicable disease control services, help the nursing sisters and matrons to
supervise subordinates and orientate visitors and new staff. They play an important role in
ensuring that the clinic and district office are managed efficiently and that high quality of
services are provided for the clients benefit. They prepare monthly, 3-monthly and annual
records and reports and help in the preparation of confidential staff report and manage data
records and reports in the clinic. The responsibilities of the staff nurse are myriad depending
on the public health setting there are posted to.

30
In the family Health Clinics, the staff nurses play a very important role in the daily running of
the Maternal and Child Health clinic which include antenatal and post natal care, child clinic,
family planning service, Pap smear and post natal home care and during emergency home
delivery. The staff nurses in the MCH clinics are allowed to manage mothers who are
categorised as green and yellow code without any medical/obstetrics problems (colour coding
system is discussed in detail in another chapter). They also see cases which are referred to
them by the community nurses and when required they refer complicated cases to the medical
officer in charge for further evaluation and subsequent treatment. They also conduct post
natal home visits especially to monitor the progress of the mothers and to review and record
the progress of the babies to detect any complications or problems early. When attending
house calls for emergency deliveries at homes, they are permitted to conduct deliveries for
low risk patients. In the child clinics, they vaccinate children according to the vaccination
schedule of the MOH. They play a role in integrating the expanded scope programmes into
the family health development activity. They are also involved in the investigation into
maternal, infant or child death.

In the outpatient clinics the nurses carry out treatment according to the attending doctor’s
instructions and help take vital signs, set IV infusion, assist in emergency treatments etc.
They help evaluate and respond to reactions to treatments. The nurses in outpatient clinics
also carry out expanded scope programmes within their job description e.g. assisting in the
diabetic, hypertension, cardiovascular, mental health, geriatric and adolescent clinics. They
are trained to provide health education and promotion. They are also involved in home care
nursing for discharged cases when needed.

A staff nurses’ responsibility is not restricted to clinic work, they also play a major role in
promoting health in the general public by participating in health campaigns, camps and
exhibitions. The staff nurses are trained to give talks on health promotion and prevention of
illnesses, health screening and in providing counselling services. They are an invaluable
member of the school health team.

Various modes of family planning services are available in the Klinik Kesihatan. It is the staff
nurses’ responsibility to counsel the patient seeking contraception and to encourage its use.
They educate the patients regarding the pros and cons of each mode of contraception and,
depending on the type, dispense the appropriate contraception to the patient. However the

31
staff nurses’ are only allowed to dispense condoms and Oral Contraceptive Pills (OCPs).
Should the patient chose Intrauterine Device (IUD) or hormonal implants, the patient is
referred to a doctor who is trained to insert and remove the IUD.

The staff nurse who mans the MCH clinic monitors the activities of the assistant nurses,
community nurses and attendants working in the clinic. She ensures that the all the records
and registries kept in the clinic are up to date and secure.

Besides attending appropriate continued professional development training, she also ensures
that her subordinates update themselves by attending Continued Nursing Education.

Like all other health professionals in the MOH, they have management roles. She ensures that
there is an adequate supply of stationary and medication for the clinic use and there is
replacement for subordinates who are on leave. She has the responsibility of writing monthly
reports on the activities of the clinic.

Ketua Jururawat Kesihatan (Nursing Sister)

A nursing sister is an experienced staff nurse with leadership qualities whose administrative
skills are used to manage the para-clinical staff for the smooth running of the clinics.

Jururawat Masyarakat (Community Nurse)

The community nurses are usually posted in ‘Klinik Desa’ and ‘Klinik Kesihatan’. The
community nurses help the staff nurses in managing the MCH and family planning clinics
and the postnatal services. Among the expecting mother they promote health and prevent
illness by giving health talks and encourage healthy lifestyles, providing vitamin, iron pills.
They also provide home care.

In the child health clinic besides the examination and assessment of children they also treat
minor illnesses, take new-born’s cord blood for G6PD testing and visit referred patients at
home. They help monitor children’s nutritional status and refer malnourished children.
Mothers are taught concerning healthy foods and proper food preparation. They help give
immunization according to the MOH schedule, provide essential vitamins and nutrition. They
also organize health talks and discussions individually or in groups.

32
They help provide family planning services by conducting routine examination, ensuring
constant supply of the family planning kits, giving advice and clarifying doubts and referring
clients when required.

They also provide outpatient treatment for minor illnesses and assist nurses and doctors
during emergency treatment and accompany referred cases to the hospital.

They conduct home visits for pregnant, postnatal, special/problematic cases which may
include pregnant women who default antenatal follow ups. The community nurses are also
involved in tracing, notifying, referring and following up cases which may include children
with special needs, selected geriatric cases, people with mental illness etc. They also help
trace TB patients who default the daily treatment

Other responsibilities include updating and preparing reports. They are trained to maintain
records using the Health Information System. Besides helping the Sister and staff nurses in
administrative work, they ensure cleanliness of the clinic and the surrounding. Just like the
staff nurses they also help in the investigation of a mother’s or child’s death. In a non-
community setting a community nurse is trained to administer Syntometrine injections to
mothers who have just delivered.

Pembantu Perawatan Kesihatan (Medical Attendant)

Assists in the running of the health clinic by organizing the patient’s register, helping in
anthropometry measurements and filling in forms. They also help to mobilize patients using
wheel chair or trolley. The assistant is also expected to send specimen samples to the
laboratory and help trace laboratory results for the doctor’s review.

Pegawai Penolong Farmasi (Assistant Pharmacist)

Prepare and dispense medications as prescribed by the physician and provide advice on the
proper intake of medications and potential adverse effects.

33
Juru Teknologi Makmal (Medical Laboratory Technician)

The laboratory assistant is responsible to ensure that all specimens are received using
appropriate specimen bottles and using proper collection techniques which are suitable for
that specific investigation. He/she is also required to report the results obtained from the
analysis.

Radiographer

The radiographer is responsible to handle the x-ray machine and to produce radiographic
images as requested by the doctor.

Driver

He is required to ferry patients to the general hospital for referral or to mobilize the health
team for home visits or health promotion campaigns. He is also required to ensure the
vehicles are properly maintained for safe and efficient use.

General Worker

The general worker maintains the cleanliness of the health clinic the proper function of the
furniture and electrical appliances of the clinic.

Nutritionist

The function of the nutritionist is to give technical support to the health clinics in matters
related to food and eating habits and offer services in improving the standards of nutrition
among the community. The nutritionist is responsible to provide dietary services like dietary
screening, counselling on healthy eating, provide advice including planning, evaluation of
programmes, planning of menu, demonstration of recipe and healthy eating in the villages/
estates/housing areas, factory, canteen/cafeteria/food premises, supermarket, in institutions
like universities, schools, preschools, prison and old folks home etc. They usually plan
healthy eating campaigns at a district level and promote healthy eating through the mass
media. “Dapur Sihat Masyarakat”, breast feeding week, healthy eating month, healthy eating
campaign, sugar reduction campaign etc. are examples of the programmes conducted by the
nutritionists.

34
A nutritionist also provide nutrition and dietary services for referred outpatient cases,
pregnant and breastfeeding mothers with nutritional problems; and infants and children,
elderly with poor nutritional status and adults who wants advice on health diet. They monitor
nutritional problems especially in children less than 6 years old, anaemic patients, pregnant
women with gestational diabetes, hypertensive patients etc. They are also part of the school
health team that helps monitor nutrition of underweight or obese school children and help
inspect the quality of the food in the school canteen.

Besides these services, the nutritionist in the district health office is responsible for food
planning and management and to identify the nutritional problems and to monitor their
nutritional status of the community. This is done by dietary data collection and analysis,
preparation and update of community nutritional profiles, reviewing the dietary monitoring
system and preparing report on the dietary status of the communities in the district. Data is
collected using the correct techniques using proper anthropometric equipment. The
nutritionist ensures that the growth chart is correctly recorded and interpreted and all dietary
records properly stored. Research is also conducted to increase the quality of service and
dietary activity. It is the responsibility of the nutritionist to ensure that all malnutrition cases
receive the proper attention. The nutritionist also monitors the distribution of full cream milk
powder under the ’Program Pemulihan Ibu Mengandung Termiskin’. A dietary action
programme plan to improve the dietary status of the communities in the district is prepared
by the nutritionist.

The nutritionists is required to create and conduct training for health staffs and monitor the
budget for the dietary programmes which includes rehabilitation programme for malnourish
children, breast feeding Programmes, monitoring the ethics of formula Milk products and
food experiments

The nutritionist usually acts as a technical advisor for many subcommittees. He or she will
advise the ‘Pegawai Peringkat Daerah’ about the progress of the dietary activities in the
Public Health Programme especially family Health, Primer, Workers Well Being, Health
Education, Food safety and Quality, Dentistry and Non-communicable Disease Control.

35
 CHAPTER 3: SCHOOL HEALTH PROGRAMMES

School is a ready and easy source of subjects and is often used in developing countries for
health education, promotion and prevention. The goal of the school health programme is to
produce healthy children who are free of remedial defects and have acquired desirable
knowledge, attitudes and habits pertaining to health, and use this information to help promote
health in the community.

The scope of the school health programme is to

 appraise each child’s health status

 identify physical, mental, and social defects or handicaps and correct these whenever
possible
 refer pupils with specific problems to the appropriate specialist or institutions of care
 formulate plans to cope with major disasters and emergency problems such as illness
and injury to children attending school and
 provide guidance to pupils, parents, and teachers on matters of health.

36
figure below shows the component of the school health programme
 Health appraisal
School health  Corrective measures
services  Preventive measure
(Immunization, sanitation)
 Cumulative health record
 Dental health

Healthful school  Healthy physical

School health environment environment
program  Healthy emotional
environment

School health  For pupils

education  For teachers
 For parents

School and  The school’s contribution

community to the community.
participation for  The community’s
health contribution to the school

37
The components of the school health programme includes school health services, health
education, healthy lifestyle in schools and co-operation among schools and community to
provide good and effective health services among students.

The mission of the school health programme is to create a healthy and safe school
environment by ensuring each school has a school health policy and a clean, safe physical
and social environment; and increase cooperation & involvement of the community in the
school health program with the delivery of knowledge and instilling a positive attitude
towards self-health, family & community.

The objectives of the school health programme is to assess the level of health of school going
children; provision of guidelines concerning the needs and health problems of school
children, to identify and provide assistance to children with physical, mental and social
disability with appropriate referrals; the provision of knowledge, instil good attitude and
behaviour relating to health and healthy lifestyle; making the school environment clean and
healthy in physical, mental and social aspects; prevention and control of communicable
diseases; and making the school free from social problems/diseases.

The services provided in this programme include

 Evaluation of the students health status - hygiene, sight, hearing, skin infections like
scabies, worm infestation, anaemia, goitre, heart anomaly, skeletal anomaly, nervous
system/epilepsy, learning disability, mental health assessment etc. Obese children and
their parents are advised to see a doctor.
 Treatment, referral and follow up of school children with health problems. If required,
nurses visit the homes of these children.
 Immunisation of school children* - Standard 1 (age 7): double antigen (diphtheria and
tetanus), MR (measles and Rubella only for this year). Girls at form 1 (aged 13):
Human Papilloma Virus vaccine and Form 3 (aged 15) Anti Tetanus Toxoid (ATT)
*subject to change

 Health education is focused not only on the students but also the parents of the
students and the school staff. Health education is also integrated in the curriculum.
Health education is conducted in classrooms, talks, dialogues, demonstrations,
exhibitions, visual aids and health quiz’s. Health education is focuses on but not

38
 limited to hygiene, puberty, social problems especially smoking, menstrual cycle
(girls), HIV etc.
 Counselling on health issues including overweight/obesity and treatment and advice
to children when necessary.
 Ensuring the school environment is free from vector reproduction, there is a proper
method of waste disposal and sewage system and the physical environment is
comfortable and safe with adequate ventilation, lighting and facilities. Safe and clean
school canteen with hygienic preparation of food
 Act as a conduit for the collaboration between school and community for health by
encouraging community and school involvement in health activities through Parents
and Teachers Association (Persatuan Ibu Bapa dan Guru), village safety and
development committee (Jawatankuasa Kemajuan dan Keselamatan Kampung),
government organisation and NGOs

Records of activity are kept and a copy of the student’s health record is given to every
student. The School health unit prepares report which is sent to the state health department
(Jabatan Kesihatan Negeri) and Putrajayaon regular basis.

Depending on the location, the school health services team may comprise of a doctor,
Assistant Medical Officer, staff nurse, community nurse attendant and driver. Each team
member has his/her own role and responsibility. School visits are conducted for students in
Standard 1, 6 and form 3 (aged 7, 12 and 15), where each student will be assessed by a
doctor. On the firstvisit the student’s immunization and health history is noted, weight and
height is measured, a general and systemic medical examination is conducted and
immunization given.

Healthy School Canteen Project

Obesity is on the rise even among school children in the country and the diseases related to
obesity in Malaysia are increasing. Healthy School Canteens Project is designed to promote
healthy eating among school children as an early effort to prevent the increasing incidence of
chronic diseases related to malnutrition such as diabetes, cardiovascular disease and
hypertension when they reach adulthood. The general objective of the programme is to

39
increase the knowledge and practices of healthy eating, food cleanliness and preparation and
safety among school canteen operators, students, teachers and parents.

Activities like food exhibition, sales of healthy food like fresh fruits and vegetables,
establishment or renovation of a cafeteria counter- 'calorie counter', talks on healthy eating
and competitions such as essay writing competition related to healthy eating, fruits and
vegetables drawing and colouring competition, competition to create recipes using fruits and
vegetables and quizzes on nutrition.

Certain guidelines on healthy meals in school canteens are set including guidelines on
choosing raw materials, food storage, food preparation starting from raw materials to
cooking, preparation of healthy meals, modifying recipes, suggestions of healthy meal
choices, ensuring premise cleanliness and sales of food and drinks in school canteens

As a result of the joint efforts between the ministries of health and education the incidences
of food poisoning in schools had decreased to 123 episodes in 2009 as compared to 230
episodes in the same period in 2008.

Doktor Muda (Young Doctor) Programme

Peer health education is an effective form of health promotion and is popular in relation to
HIV prevention and sexual health promotion. Peer education is about students learning about
health from other students. The Doktor Muda programme started in 1989 in a primary school
in Pekan, Pahang and later was introduced nationwide. The ministry of health’s “Doktor
Muda” programme involves the empowerment of knowledge and skills relating to basic
health to standard 4, 5 and 6 students (aged 10, 11 and 12). The ‘Doktor Muda’ are selected
by the schools to act as peer mentors based on the students interest, academic performance,
talent, leadership quality, with interest to help others, proactive and possess a good
personality. The selected students must obtain permission from their by parents to join the
programme. They become educators and agents of transformation to their peers by acting as
role models, health promoters and motivators to the positive change of knowledge,
behaviour, and health practices among students, family members and the community in
general.The “Doktor Muda”is taught to always practice a healthy lifestyle, and to be role
models for friends and family members and encourage them to be hygienic, positive and to

40
practice healthy lifestyle by conveying health information and by helping build a healthy and
clean school environment.

The objective of the programme is to - increase the knowledge and skills concerning the
general health of primary school students to empower them to adopt a healthy lifestyle and to
guide and inspire their peers and family members to adopt a healthy lifestyle as well;help
health care providers and schools in carrying out health activities in schools; encourage
parents or guardians to pay more attention towards their children’s health; and strengthen the
involvement of teachers and other school staff in an effort to improve students health.

The programme is successfully implemented by a smart partnership between the health

department, and education department with the help of school authorities, parents/caretakers,
other governmental organizations, private sectors and non-governmental organizations.
Committees are formed at national, state, district and school level in order to synchronize and
monitor the activities.The programmes are gradually implemented in the schools based on
available resources.

The activities of the programme Doktor Muda include

Healthy lifestyle: to educate fellow students and family members regarding personal hygiene
and encourage healthy lifestyle practices including healthy diet, exercise,stress management
etc. by organizing health education activities, providing health related information and
managing health information corner in schools for the students as well as teachers.

Create clean, healthy and safe environment in schools:Promote proper waste disposal and the
toilet hygiene among friends and family members and monitor cleanliness of the school and
its environment and identify and destroy mosquito breeding places. A ‘Doktor Muda’ will
organize health service activities at school including measuring weight, height and vision,
examining the ears, hair, nail, oral cavity and school uniforms.

Reporting incidence of disease/ health problems: to inform the teacher in charge concerning
incidences of fever, vomiting, etc.

Treating minor injuries: to treat minor injuries such as wounds and abrasions.

41
Documentation of activities: Record the health activities, healthy and unhealthy practices
which were observed in school and house, in record books and give suggestions to overcome
the problems.

Other activities: organize/participate/ assist in health campaigns and activities that will
increase health awareness and to participate in ‘Convention Day’ for Doktor Muda and field
visits to health centers.

This young doctor programmes has the potential to instill healthy habits among the students
at the primary level. The school children also receive basic knowledge and skills of health
and are able to appreciate health by forming positive attitudes to health care. They also
acquire and practice communication skills and develop leadership skills and confidence. The
programme will increase the level of personal hygiene and decrease cases of food poisoning
and infectious diseases.

Germ Buster

The Germ Buster Program involves the Germ Buster squad educating school children on food
safety promotion and dengue prevention. Exhibitions and talks on food safety in school are
conducted to avoid food poisoning. Students are taught to choose clean and safe food and to
shun away from foods which are unhygienic and have banned additives and colouring. Food
poisoning prevention is also aimed at parents, teachers and canteen operators

The students are thought to ‘See, Smell and Taste’. The first step is to look for colour
alteration of the food, slime on food, the expiry date and shape of cans, bottles or packaging.
The second step is to smell i.e. to look out for unpleasant smell in food. And the third step is
to taste and identify or rotten food.

Other activities include promoting proper hand washing, health talks, exhibitions, games and
demonstrations and the teaching the students to recognize Aedes mosquitoes and its larvae.
The students are also briefed on the various ways of preventing dengue fever.

42
School Dental Services

The school dental service was introduced in the mid 1980’s. This service is provided for free
for primary and secondary government sponsored school children. A comprehensive and
systematic dental healthcare is given to ensure that school children have good oral hygiene.
Dental nurses are responsible for examining and giving treatment to the school children under
the supervision of a dentist. A specially prepared room for the school dental clinic is located
in selected primary or secondary government schools. A mobile dental team which provides
dental health services is available for students living in rural areas. The MOH also provides
mobile dental clinics in vehicles modified and equipped with dental equipment. The clinic
provides services to students in schools that have limited space. The services include dental
health education, examination, and filling, scaling and polishing. If a complicated treatment is
required, student will be referred to a dental officer or specialist.

HPV Immunization

Cervical cancer is the second most common cancer in women worldwide after breast cancer.
Almost 95% of the 500,000 new cases and 250,000 deaths due to cervical cancer each year
are caused by human papillomavirus (HPV) infection.The age standardized incidence rate
(ASR) for cervical cancer in Malaysia is 19.7 per 100,000 women. There is an average of
2000 to 3000 hospital admissions of cervical cancer cases per year in Malaysia, most of them
presenting late into the disease. The economic burden due to cervical cancer is enormous. It
costs about RM312 million to manage cervical cancer annually in Malaysia, 67% of which is
spent managing invasive cancer cases. The annual cervical cancer death rate in Malaysia is
5.6 per 100,000.

In 2006, the U.S. Food and Drug Administration (FDA) approved the first HPV vaccine. The
HPV vaccine contains protein subunits of the actual virus and may prevent infection with
certain species of HPV associated with the development of cervical cancer, genital warts and
some less common cancers. The HPV immunization program in Malaysia was implemented
in year 2010 with the objective to reduce the national burden of cervical cancer over the next
20 years.HPV vaccination was started by the ministry of health because widespread
vaccination of females against HPV can potentially prevent 89% of cervical cancer cases at a
steady rate and could potentially lead to annual savings of over RM45 million in terms of
HPV related treatment costs. Howeverthe ultimate success of HPV vaccines in reducing the

43
incidence of cervical cancer will be dictated by its uptake. It is believed that uptake of about
80% is required for "herd immunity".The Malaysian government spends RM150 million
annually to operate the nation’s HPV immunization programme.

It is given free to Malaysian girls aged 13 years old either in schools or in clinics. Prior to
2010, HPV vaccination was only available in private clinics and hospitals and the cost of
vaccination was about RM1200. The Ministry of Health Malaysia had launched a massive
advertising effort in collaboration with non-governmental organizations such as the National
Cancer Society and pharmaceutical companies to educate and make aware of the HPV
vaccine since 2010 resulting in the high rates of awareness of HPV vaccines. The vaccination
is given in two doses at the age of 13 years. Second dose of the vaccine is given 6 month
after of the 1st dose.

School health team visits the schools to immunize Form 1 students (age 13), and to conduct
educational activities to increase the awareness on cervical cancer and the importance of
HPV vaccination.

Many different units are responsible for the success of this programme. The Disease Control
Unit is responsible in the preparation of the budget in relation to the HPV vaccine which
includes procurement of relevant equipment’s such as refrigerators for appropriate storage of
the vaccine, sufficient stock of HPV vaccine for all the centres providing HPV immunization.
The centre is also responsible to evaluate the effectiveness of the programme towards
prevention of cervical cancer. The Family health development division is responsible to
develop and distribute action plan in implementing the national HPV immunization
programme, to brief and make aware the health care workers concerning the programme and
to evaluate the effectiveness of the programme in the prevention and control of cervical
cancer. Health Education Unit is responsible to promote and educate the public on the
importance of participation in this programme, to disperse information by pamphlets, news
coverage and to evaluate the effectiveness of all these promotional activities. The pharmacy
division is responsible to monitor the quality of the vaccine, monitor and investigate adverse
effects and propose methods for improvement. The State Health Department is responsible to
determine the ways of implementing the programme in the state, estimate the amount of
vaccine needed, select participating clinics to provide HPV immunization to non-schooling
13 year old female teenagers and those who defaulted their jabs previously and to oversee the
implementation of the programme in all the districts. The District Health Office is responsible

44
to form the team in charge of implementing this programme in the district area, ensure
sufficient vaccine is available and to obtain permission from the District Education Office to
carry out vaccination in all secondary schools. The Hospital and outpatient department is
responsible in providing treatment to individuals who develop side-effects, educate the public
about HPV immunization and to identify eligible female teenagers aged 13 who have not
received their vaccination and to refer them to the clinics chosen to participate in this
programme. The school team is responsible in carrying out HPV immunization of Form 1
school students, ensure sufficient amount of vaccine is available, provide treatment and if
necessary refer any individuals who develop side effects and to maintain a record students
who participated in the programme.

45
 CHAPTER 4: PEJABAT KESIHATAN DAERAH (DISTRICT HEALTH
OFFICE)

Objectives of health services at the district level is to provide preventive and curative health
services that is effective, efficient and comprehensive especially to communities in rural
areas, to decrease the incidence and prevalence of communicable and non-communicable
diseases and to promote the culture of healthy living.

Objective of the services provided in by the health department is to

1) upgrade the health facilities

2) upgrade health care
3) improve the health of the community
4) increase the health awareness of the community
5) reduce mortality rate
6) improve physical, mental and social state of the community

There are a myriad of public health units within the district health office which include
family development, administration and environmental health. The main functions of the
‘Pejabat Kesihatan Daerah’ include the

 implementation of the state health recommendations and laws and

 to monitor and evaluate programmes and the efficiency of the daily operations of the
‘klinik kesihatan’ (health clinics) and ‘klink Desa’ (community clinics) which are
under the jurisdiction of the district health office. Feedbacks are received from the
two clinics and solutions to problems, if any, are found and implemented.

Reports concerning the progress of the programmes within the jurisdiction of each of the
district health office is prepared and sent to the state level. As of 2012, there were 166
‘Pejabat Kesihatan Daerah’ (district health offices) throughout Malaysia. In Penang there are
5 district health offices corresponding to the five districts in the state.

46
 District Health Officer

Management Family Health Disease Control

Administration Maternal and Communicable

Child Health Diseases

Services
Health education
Primary care and promotion

Finance
School Health Non-
communicable
diseases

Food safety and

quality

KMAM

Occ. Health
BAKAS

Figure showing the general organization of a district health office

Human Resources at the ‘Pejabat Kesihatan Daerah’ and the Clinics under it

1. Pegawai Kesihatan Daerah (Medical Officer of Health @ district health officer)

The responsibility of the Pegawai Kesihatan Daerah (PKD) is to

1. plan, implement, and evaluate the Public Health Programmes within its jurisdiction
2. implement the health administration management and manage the finances of its
department
3. ensure the development of human resources by providing courses to new staff
4. improve the relationship between the government agencies and the private sector
5. improve the knowledge and attitude of the society towards health

47
 6. provide technical and administrative orders and to supervise the activities of his/her
team who are working in the health clinics or in a special team e.g. the school health
team
7. to be involved as a member in the board of schools and district development society
8. encourage research
9. improve the standard of health of the community.

10. perform epidemiological investigations on prevention and surveillance plans for

infectious diseases. Supervise prevention and control of infectious diseases. Oversee
the immediate investigation of infectious diseases reported or notified for source
tracing and detection of disease contacts to prevent disease spread and recommend
appropriate control and preventive measures. The medical officer of health may order
the assistant environmental health officer (Penolong Pegawai Kesihatan Persekitaran)
involved to prepare and organize all graphs, flow-charts and important data
concerning infectious diseases. He or she will also supervise the preparation of daily,
weekly, monthly, quarterly and yearly reports involving infectious disease cases.

11. supervise family health development

2. Pegawai Kesihatan Daerah II

In certain districts, especially bigger and busier districts, there may be another Medical
Officer of Health known as the ‘Pegawai Kesihatan Daerah II’ who is responsible in assisting
the PKD I in

1. planning, implementing and evaluating the Public Health Programmes

2. implement the health administration management and management of the finance
department
3. give technical and administrative orders and supervise the activities of the teams that
are working in the health clinics or in a special team e.g. school health team.
4. implementing the orders of PKD1

48
3. Family Medicine Physician

A family medicine physician @ specialist (FMS) is a primary care physician because he or

she is usually the first contact for a person with an undiagnosed health concern. The FMS
also provides continuing care for varied medical conditions. The FMS heads the primary care
centre and is capable of treating simple and complicated general health conditions at an
outpatient setting. The FMS is also entrusted with creating and promoting health awareness
programs as instructed by the district health office.

4. Pegawai Perubatan dan Kesihatan (Medical and Health Officer)

The medical and health officer reports to the Family Medicine/Clinical Specialist and is
stationed at the outpatient clinic and provides consultation services to patients who come to
the outpatient department and to the maternal and child health clinics. The medical and health
officer also supervisors the school health team.

The responsibilities of the medical and health officer includes

11. manage patients in the outpatient department which may be new or follow up cases. In
some centres patients on methadone replacement therapy are also assessed which
include adjusting the methadone dosage, monitoring withdrawal symptoms and
looking out for substance abuse and if necessary refer cases to hospital
12. conduct routine health check-ups, treatment and referrals when required
13. in the maternal and child health clinic the medical and health doctor is responsible for
patients attending the prenatal, antenatal and postnatal clinics. He/she will also attend
to patients referred from ‘Klinik Desa’ and ‘Klinik 1Malaysia’ for pregnancy induced
hypertension, gestational diabetes, excessive weight gain during pregnancy, small for
gestational age etc. The medical and health officer is trained to perform ultrasound
scans for dating purposes at ≥ 12 weeks and placenta at ≥ 24 weeks. They also
provide advice on family planning including insertion of Intra Uterine Devices
14. conduct health promotion and awareness activities by giving health talks, conducting
focus group discussions, conducting Continuous Medical Education (CME) and
courses for staffs
15. conduct home visits
16. evaluate the activities of maternal child health and the outpatient clinics

49
 17. being a valuable member of a team by working together with the other health units
18. visit and supervise the community clinics (klinik desa)
19. monitor the daily requirement of the human resource of the clinic by approving or
disapproving leave for the staffs under his/her care and evaluate the work
performance of the staffs under his/ her care
20. sign birth registration forms
21. approve the place of delivery for expecting mothers under their care
22. attend meetings including heads of unit meeting, basic health development meetings,
and when necessary meetings with the hospital/health/dentistry department
23. attend courses/seminars for self-professional development
24. substitute a colleague who is on leave

5. Penolong Pegawai Kesihatan (Assistant Medical Officer)

An assistant medical officer, previously known as medical assistant, has the responsibility to
examine, diagnose, and treat patients under the supervision of a physician. They may also run
the health clinic in the absence of a medical doctor. They also have the responsibility of
performing a wide range of non-clinical functions necessary for the efficient and smooth
delivery of health care delivery such as the completion of medical records.

6. Jururawat Kesihatan (Staff nurse)

They manage all nursing activities related to family medicine and they play an important role
in ensuring that the clinic and district office are managed efficiently and that the services
provided are of a high quality. Besides this they are also involved in

 communicable disease control services

 helping the nursing sisters and matrons in the supervision of subordinates
 orientation of visitors and new staff
 preparing reports at specific intervals
 preparing confidential staff report and
 manage data records and reports of the clinic.

50
There are other myriads of responsibilities of the nurses depending on the public health
setting there are posted to. In the family health clinics, the staff nurses play a very important
role in the daily running of the Maternal and Child Health clinic which include antenatal and
post natal home care and during emergency home delivery, child clinic, family planning
services, Pap smear etc.

In the MCH clinics, these nurses are allowed to manage mothers who are green and yellow
coded i.e. expecting mothers without any medical/obstetrics problems (the colour coding
system is discussed in detail in another chapter). The nurses also see cases which are referred
to them by the community nurses and when required they refer complicated cases to the
medical officer in charge for further evaluation and subsequent treatment. When attending
house calls for emergency deliveries at homes, they are permitted to conduct deliveries for
low risk patients.

They also conduct post natal home visits especially to monitor the progress of the mothers
and to review and record the progress of the babies to detect any complications or problems
early. In the child clinics, they vaccinate children according to the vaccination schedule of the
Ministry of Health.

They play a role in integrating the expanded scope programmes into the family health
development activity. They are also involved in the investigation into maternal, infant or
child death.

In the outpatient clinics, the nurses carry out treatment according to the attending doctor’s
instructions and help take vital signs, set intravenous infusion, assist in emergency treatments
etc. They help evaluate and respond to reactions to treatments. In the outpatient clinics they
carry out expanded scope programmes within their job description e.g. assisting in the
diabetic, hypertension, cardiovascular, mental health, geriatric and adolescent clinics. They
are also involved in home care nursing for discharged cases when needed.

The nurses are also trained in the art and science of health education and promotion. They
play a major role in promoting health in the general public by participating in health
campaigns, camps and exhibitions. The staff nurses give talks on health promotion and

51
prevention of illnesses, health screening and provide counselling services and they are an
important member of the school health team.

For the family planning services in the Klinik Kesihatan, it is the staff nurses’ responsibility
to counsel clients seeking contraception and to encourage its use. They educate the patients
regarding the advantages and disadvantages of each mode of contraception and, depending on
the type, dispense the appropriate contraception. However, the staff nurses’ are only allowed
dispensing condoms and Oral Contraceptive Pills. Should the patient chose Intrauterine
Device or hormonal implants, the patient is referred to a doctor who is trained to insert and
remove the Intra Uterine Device.

6. Ketua Jururawat Kesihatan (Nursing Sister)

A nursing sister is an experienced staff nurse with leadership qualities whose administrative
skills are used to manage the para-clinical staff for the smooth running of the clinics.

7. Bidan (Midwife)

A midwife is a registered nurse with post-basic training in midwifery. Besides monitoring

normal pregnancy and assisting in childbirth and providing nursing care during the
postpartum period, she is also trained to recognize and deal with pregnancies and deliveries
that are abnormal and referring patients when they require care beyond her area of expertise.

8. Jururawat Masyarakat (Community nurse)

The community nurses are usually posted in ‘Klinik Desa’ (community clinics). They assist
the staff nurses in managing and promoting health and preventing illness in the maternal and
child health clinics.

In the child health clinic the community nurses examine and assess the children, treat minor
illnesses, take new-born’s cord blood for G6PD testing and visit referred patients at home.
They help monitor children’s nutritional status and refer malnourished children. They teach
mothers concerning healthy foods and the proper technique of food preparation. They also
help give immunization according to the ministry of health schedule.

52
They also organize health talks and discussions individually or in groups.

They help provide family planning services by conducting routine examination, ensuring
constant supply of the family planning kits, giving advice and clarifying doubts and referring
clients when required.

In the outpatient treatment they assist nurses and doctors during emergency treatment and
accompany referred cases to the hospital.

They conduct home visits for pregnant, postnatal, special/problematic cases which may
include pregnant women who default antenatal follow ups. They are also involved in tracing,
notifying, referring and following up certain selected cases which may include children with
special needs, selected geriatric cases, people with mental illness etc. They also help trace TB
patients who default daily treatment.

Other responsibilities include updating and preparing reports, helping the sister and staff
nurses in administrative work, ensure cleanliness of the clinic and the surrounding, may be
involved in the investigation of a mother’s or child’s death.

9. Penolong Juruwat (Assistant Nurse)

In the health clinic, they assist in anthropometry measurements, filling up medical forms and
assist with the mobilization of patients.

10. Pembantu Perawatan (Medical Attendant)

They assist in the running of the health clinic by organizing the patient’s register, helping in
anthropometry measurements and filling in forms. They also help to mobilize patients using
wheel chair or trolley and send specimen samples to the laboratory and help trace laboratory
results for the doctor’s review.

11. Pembantu Farmasi (Assistant Pharmacist)

Prepare and dispense medications as prescribed by the physician and provide advice on the
proper intake of medications and potential adverse effects.

53
12. Juru Teknologi Makmal (Laboratory Technician)

The laboratory assistant is responsible to ensure that all specimens are received using
appropriate specimen bottles which are suitable for that specific investigation. He/she is also
required to report the results obtained from the analysis.

13. Radiographer

The radiographer is responsible to handle the x-ray machine and to produce radiographic
images as requested by the doctor.

14. Driver

He is required to ferry patients to the general hospital for referral or to mobilize the health
team for home visits or health promotion campaigns. He is also required to ensure the
vehicles are properly maintained for safe and efficient use.

15. General Worker

The general worker maintains the cleanliness of the health clinic the proper function of the
furniture and electrical appliances of the clinic.

16. Nutritionist (Pegawai Zat Makanan)

The function of the nutritionist is to give technical support to the health clinics in matters
related to food and eating habits and offer services in improving the standards of nutrition in
the community. The nutritionist is responsible in providing dietary services like dietary
screening and counselling on healthy eating. They also provide advice including planning,
evaluation of programmes, planning of menu, demonstration of recipe and healthy eating in
residential areas, work premises, supermarket, in institutions like universities, schools,
preschools, prison and old folk’s home etc. They usually plan healthy eating campaigns at a
district level and promote healthy eating through the mass media. “Dapur Sihat Masyarakat”,
breast feeding week, healthy eating month, healthy eating campaign, sugar reduction
campaign etc. are examples of the programmes conducted by the nutritionists.

A nutritionist also provide nutrition and dietary services for referred outpatient cases,
pregnant and breastfeeding mothers with nutritional problems; and infants and children,

54
elderly with poor nutritional status and adults who wants advice on healthy diet. They
monitor nutritional problems especially in children less than 6 years old, anaemic patients,
pregnant women with gestational diabetes, hypertensive patients etc. They are also part of the
school health team that helps monitor nutrition of underweight or obese school children and
help inspect the quality of the food in the school canteen.

Besides these services, the nutritionist in the district health office is responsible for food
planning and management and to identify the nutritional problems and to monitor their
nutritional status of the community. This is done by dietary data collection and analysis,
preparation and update of community nutritional profiles, reviewing the dietary monitoring
system and preparing report on the dietary status of the communities in the district. Data is
collected using the correct techniques using proper anthropometric equipment. The
nutritionist ensures that the growth chart is correctly recorded and interpreted and all dietary
records properly stored. Research is also conducted to increase the quality of service and
dietary activity. It is the responsibility of the nutritionist to ensure that all malnutrition cases
receive the proper attention. The nutritionist also monitors the distribution of full cream milk
powder under the ‘Program Pemulihan Ibu Mengandung Termiskin’. A dietary action
programme plan to improve the dietary status of the communities in the district is prepared
by the nutritionist.

The nutritionists is required to create and conduct training for health staffs and monitor the
budget for the dietary programmes which includes rehabilitation programme for malnourish
children, breast feeding Programmes, monitoring the ethics of formula Milk products and
food experiments

The nutritionist usually acts as a technical advisor for many subcommittees. He/she will
advise the ‘pegawai peringkat daerah’ about the progress of the dietary activities in the Public
Health Programme especially family Health, Primer, Workers Well Being, Health Education,
Food safety and Quality, Dentistry and Non-communicable Disease Control.

55
17. Penolong Pegawai Kesihatan Persekitaran (Assistant Environmental Health
Officer@ health inspectors)
Besides administrative work, the ‘Penolong Pegawai Kesihatan Persekitaran’ (PPKP) assists
the Medical Officer of Health in health education, and organizing activities to control and
prevent disease.

For efficiency, they are divided into several teams which include

1. Communicable disease control team

The communicable disease control team is responsible to collect, analyse and record data on
communicable diseases. They investigate and identify causes of the reported cases and collect
specimens and prepare report. Their activities include ensuring environmental cleanliness e.g.
rural toilet and sewage system, ensuring the quality of drinking water and food premise
inspection as part of food quality control.

2. Non communicable disease team

The non-communicable disease team conduct the cleanliness and safety checks in
kindergarten and schools. They are also responsible for the ‘Kawalan Hasil Tembakau 2004’
(KHT) and ‘Reten Jerebu’ weekly.

3. Vector control team

Upon receiving notifications through telephone/fax/by hand, they prepare an investigation
form and start investigation regarding the case. A report is send to the State Health
Department concerning the case. The team also conduct checks for vector breeding areas and
they organize activities to control and prevent disease such as fogging.

4. Food quality control team

The responsibility of this team is to implement the ‘Akta Makanan 1983’ and ‘Peraturan
Makanan 1985’. Food premises, factories, distribution and packaging including drinking
water/mineral water packaging factories are inspected for cleanliness and quality and when
required food sample is taken for analysis. They conduct investigations in cases of food
poisoning and public complaints regarding food quality and cleanliness. They also enforce
rules regarding seizing of food, closure of food premises, control of tobacco products and
court room litigations. To increase the awareness of food hygiene and the food premises, they

56
act as health educationist to managers and food handlers. The PPKP are required to prepare a
monthly budget and report of the food safety and quality unit.

5. Occupational and environmental health

This team investigates and notify occupational diseases and promote health and safety at the
work place by giving health talks, organizing seminars, performing hazard analysis etc.

6. Health promotion unit

The responsibility of this team is to increase health awareness amongst the community by
conducting health education and health promotion at all levels in the community.

7. BAKAS (Bekalan Air & Kesihatan Alam Sekitar)

This team is responsible for the improvement of the health status of rural communities by
ensuring safe water supply to the community and availability of proper sanitation. They
ensure that all public water supplies in urban and rural areas are safe and free from any
physical, bacterial and chemical pollutant. They assist the villagers in building their own
water sources in a safe manner and if required assist in drilling of wells.

8. HIV/AIDS
This team conducts health promotion programmes for HIV/AIDS and cooperate with the
school education team in promoting PROSTAR.

9. KMAM (Drinking Water Quality Control)

They ensure safe and good quality of water by working with the Water Works Department.
This team sample water weekly at peripheral water station (sampling points) and 6 monthly at
treatment plants (every 6 months).

57
 CHAPTER 5: MATERNAL AND CHILD HEALTH

Maternal and child care services in the ministry of health Malaysia incorporates
promotive, preventive and curative programmes with the objective of ensuring that every
mother and child maintains good health.

A. MATERNAL HEALTH

The main focus of maternal health is to ensure safe motherhood through various stages of
care - pre pregnancy, antenatal, intra-partum and postnatal period. The services are
available in all Klinik Kesihatan (health clinics), Klinik Kesihatan Ibu dan Anak (Maternal
and Child Health Clinic) and Klinik desa (rural health clinics).

Historically pre-independence, the services were carried out mainly by nurses as doctors
were scarce. With time the maternal health delivery service along with other health care
services has advanced exponentially. In the current primary health care settings, due to the
availability of family medicine specialists, bigger pool of medical officers and nurses
trained specifically in maternal health has resulted in the improvement in the quality of
service.

Health infrastructure

The maternal health delivery services in the early days were managed through a three tier
system. The first tier was midwife clinic manned by trained midwives. The clinic catered
for a population of 2,000. All referrals from the midwife clinics would go to a sub-health
centre. In the sub-health centre had more manpower including a doctor, staff nurses,
assistant medical officer and a laboratory technician.

58
In 1971, the system was upgraded to a two tier system. Each Klinik desa (KD) or
community clinic was manned by at least two community nurses. All antenatal cases seen
here are referred to a medical officers stationed in Klinik Kesihatan (KK) @ Health clinics.
The average distance between each KD and KK is approximately 3to 4km.

59
MCH Services

At the district level, the health department’s contribution to the improvement of the maternal
and family health services is by having a systematic health delivery system, skilled birth
attendants, trained midwifes and skilled nurses. In certain remote the Traditional Birth
Attendants (TBA) still play a role in health care. The TBA are involved in health promotion
and education campaigns, use of the tagging system as a risk approach to maternal health
care, having a quality assurance programme and Confidential Enquiry into Maternal Deaths
(CEMD).

Services provided in the maternal and child health clinics of the ministry of health Malaysia
include:
1. Prenatal Screening
2. Antenatal Care
3. Postnatal care
4. Family planning (Contraception Clinics)
5. Home visit: post-partum care
6. Child care

Pre-pregnancy Care

Safe pregnancy is an integral component of the maternal and child health care service of the
ministry of health. Pre-pregnancy care concerns with having a favourable physical and
physiological environment for a couple to ensure enhanced mother and child health status
latter.

Among the objectives of the pre-pregnancy care are to provide couples with an opportunity to
achieve safe and successful pregnancy and to reduce maternal and perinatal morbidity and
mortality by providing appropriate and adequate information, health promotion and
education, and screening and counselling to prospective parents.

The services are targeted to couples who are intending to get married and women who are
married and planning to get pregnant. Special attention is given to those with medical
illnesses, previous miscarriages or stillbirths or early neonatal death, parents with inherited
abnormalities, and parents with babies with congenital abnormalities. Special attention is also

60
paid to potential mothers who are less than 18 and potential mothers who are more than 35
years old and potential mothers with a high risk life styles like smoking, alcoholism,
substance abuse, high risk sexual behaviour, obesity and potential mothers with specific risk
factors like recurrent miscarriage, ectopic pregnancy, blood group incompatibility, chronic
medical illness, previous surgical operation etc.

Antenatal care
Antenatal care is the care given within the period of pregnancy until the delivery. The
objectives of antenatal care include assessing the maternal health and identifying high risk
pregnancies by obtaining a thorough history and conducting appropriate examinations,
clarifying any queries of the mother or her family, advising the mother concerning the
importance of good physical and mental health during pregnancy, preparing the mother for
delivery and providing advice on lactation and child health care. Every mother is expected to
visit the Klinik Kesihatan for Antenatal care for a minimum of 8 visits out of an ideal 14
times expected in each pregnancy (booking visit inclusive).

‘Booking’ or the first antenatal visit is done after a positive Urine pregnancy Test and is
encouraged before week 12 of pregnancy. During the visit, a follow up book (famously
known as the ‘buku merah’ (red book) among mothers) is given to the expectant mother and
another copy of this book is kept in the antenatal clinic for reference. The follow up antenatal
visits are once a month starting from the first visit until 28 weeks of gestation, once every 2
weeks from 28 to 36 weeks of gestation and once a week after 36 weeks until the delivery.
However, in cases of high risk pregnancy such as women with pre morbid diseases or
Gestational Diabetes Mellitus (GDM), Pregnancy-Induced Hypertension (PIH) etc. the
patient is required to attend the clinic on a more regular basis.

61
 ‘Buku Merah’

During the first visit, detail obstetric, medical, surgical, family planning method, family
history and social history are recorded. Physical examination involving anthropometric
measurements, vital signs, and complete body systems examination are conducted. During
this first visit (for every pregnancy) selected basic laboratory investigations are carried out –
Urinalysis, Hb, blood grouping and screening for syphilis (VDRL and TPHA), FBC for
Thalassemia screening and HIV rapid test performed. Based on history and examination
findings, further tests if indicated are conducted including modified glucose tolerance test,
renal function test and HIV confirmatory test – Western Blot test for confirmation and
Hepatitis B antigen (HBsAg). Dental check-up is also done during ANC visit, not necessarily
at booking, but at least once during each pregnancy.

Ultrasound scanning is done to confirm the estimated date of delivery. Ultrasound, when
done before 24 weeks of gestation, gives a reliable estimation of the date of delivery.
Routinely, Ultrasound scanning is done at least three times in each pregnancy – before 12
weeks of gestation (or first visit), at 24 weeks and 28 weeks of gestation. Haematinics i.e.
Folic acid 5mg and vitamin B complex and Vitamin C supplement are given during the first
visit, however, if the first visit is after 12 weeks of gestation then ferrous fumarate 200 mg
supplement is added. During this first visit nutritional advice and health education on the
benefits of breast feeding is also given.

For the subsequent visits, a quick history, weight and blood pressure measurement is taken
and urine test for protein and glucose is done. Blood pressure is monitored regularly to detect
pregnancy induced hypertension (PIH) and prevent its complications like pre–eclampsia and

62
eclampsia. Screening for diabetes is done regularly for early detection of gestational diabetes
mellitus (GDM) and prevent macrosomia and Intrauterine Growth Restriction (IUGR).
Similarly urine albumin levels are monitored regularly to detect renal disease and
complications of hypertension. Expecting mothers who are at risk of poor antenatal care, non-
compliance, inaccessibility to the health clinic and socio-economic problems are given
special attention. A medical examination is carried out by a qualified doctor at least twice
during the course of the pregnancy preferably during the first visit (at booking) and 32 weeks
of gestation, however this is done more regularly if there is any complication with the
pregnancy. Depending on the outcome of the examinations, the expectant mother may
continue her follow up with the nurses or is referred to medical officer, family medicine
specialist or the O&G specialist.

Antenatal classes involving the expecting mothers and their spouse are conducted to
empower parents with information on the importance of a healthy environment for their child.
The activities carried out in these classes include- advice on the importance of maintaining a
well-balanced diet such as one that is high in protein; maintaining an adequate supply of
vitamins, iron, calcium and folic acid throughout the pregnancy; maintaining good hygiene;
importance of exercises like pelvic lifts, stomach or abdominal exercises, squatting, pelvic tilt
etc.; information on normal development of baby, labour and delivery, basic baby care, breast
feeding and family planning.

Risk factor screening using the colour coding system is deployed in the antenatal clinics of
the ministry of health. At present red, yellow, green and white are the four different colour
codes used to label the risks and the appropriate care. The table below shows the colour
coding system deployed by the maternal health clinics of the ministry of health Malaysia.

The colour code given to a pregnant mother may change from time to time based on
presence/absence or worsening/improvement of certain risk factors. The new tag is placed on
the old one such that the old tag is not completely covered up (the edge of the old one is still
left visible), and the date the change was made is recorded.

63
Colour Condition Place of care Officers responsible Place of delivery
RED Eclampsia. Hospital O&G specialist/FMS Hospital
Pre-eclampsia. (with urine
albumin >1+, BP>140/90
mmHg)
High blood pressure
≥170/110 mmHg
High blood pressure
>140/90 mmHg with
symptoms
Heart disease during
pregnancy with signs and
symptoms (eg
breathlessness, palpitation)
Shortness of breath during
mild activities.
Uncontrolled DM with
glycosuria and ketonuria.
Bleeding per-vagina.
Abnormal foetal heart beat.
Anaemia with symptoms
or Hb ≤ 7gm%
Premature contraction.
Leaking liquor.
Severe asthma attack.
Convulsion
Prolonged fever ≥5 days
YELLOW HIV positive. Hospital/Health Centre -Early referral to O&G Hospital
Hepatitis B positive. specialist/FMS within 48
High blood pressure (> hours
140/90 and < 160/110 -Subsequent care by MO
mmHg), with negative and staff nurse
urine albumin.
DM with insulin treatment
Decreased foetal heart rate
at period of gestation
<32weeks.
Decreased fetal movement
at a period of gestation
>32weeks
Pregnancy exceeding
7days after EDD
Single mother and teenage
mother (<19 years)
Hb 7-9gm% or
symptomatic
Stable placenta previa with
no bleeding
Maternal pyrexia >38C or
>3days
History of infertility state
before the current
pregnancy
Heart disease without
symptom
Drug addict/smoking
Mothers with
TB/malaria/syphilis
GREEN Rhesus negative. Health Centre Referral for MO at health Hospital
Weight at booking <45 kg clinic following standard
or >80 kg. appointment guideline
Previous gynae. surgery.
Substance abuse and
smoking.
Unsure of last LMP.
History of abortion >3
times continuously.
Past obstetric history.
-Previous caesarean
section
-History of PIH, eclampsia
and DM.
-Foetal death
-Perineal tear third degree

64
 -Retained placenta
-Postpartun hemorrhage
-Assisted delivery
-Prolonged labour
-History of baby weight
<2.5kg or >4kg
Multiple gestation eg twin
Blood pressure of 140/90
mmHg with negative urine
albumin.
Haemoglobin 9 to < 11
gm%.
Albuminuria ≥ 1+
Increase in weight >2 kg in
one week.
Mal-presentation at 36
weeks gestation
Head not engaged at term
(37 weeks) for
primigravida
GDM (diet controlled)
Static body weight
Current medical problem
(including psychiatric and
physical disability), except
diabetes and hypertension
Mother’s age >40 kg
Primigravida
Gravida 6 and above
Gap between delivery <2
years or >5 years
Mother’s height <145 cm

WHITE Gravida 2 to 5. Health Centre Care by staff nurse or Alternative birth

No past obstetric problems. community nurse centre/Home/Hospital
No past medical history.
No complicated
pregnancies before.
Appropriate housing
environment.
Mother’s height more than
145cm.
Mother’s age >18 and <40.
Married mother with good
family support.
Period of amenorrhea is
more than 37 weeks and
less than 41 weeks.
Estimated foetal weight is
from 2kg to 3.5kg.
Colour coding system

Expecting mothers are given anti-tetanus toxoid (ATT) vaccination in different doses
depending on the period of pregnancy. For primigravidae, anti–tetanus toxoid injections are
given at quickening (16 to 20 weeks of gestation) and the second dose is administered 4 – 6
weeks after that. For multigravidae, ATT booster is given at 20 weeks of gestation.

During the antenatal period, the well-being of the expecting mother and the foetus is
monitored. Assessment is done by measuring the symphysio-fundal height using a simple
measuring tape done routinely from 16 weeks of gestation onwards in all pregnancies, lateral
and deep pelvic palpation and auscultation of the foetal heart is also done regularly. If a

65
discrepancy is found between the symphysio-fundal height and period of amenorrhoea (POA)
of +/- 3cm, the patient will be thoroughly examined to determine whether wrong dates, twin
pregnancy or compromised fetal well-being could be a reason for this. The mother will be
referred to medical officer or family medicine specialist for further management.

During the antenatal visit the mother is assessed for weight gain at every visit. A normal
weight gain of about 0.5kg per month for the first 20 weeks and 0.5kg per week from week
20 onwards is expected. In total a 10-12.5kg weight gain is expected.

Foetal kick chart is a fairly reliable and economical indirect tool to monitor the foetal well-
being. The expecting mothers, especially primigravidae, are taught by the nurses on how to
fill in the charts and the significance of identifying foetal movements. The expecting mothers
are given the foetal movement chart from 28 weeks gestation onwards and are advised to visit
the nearest health clinic if foetal movements are less than 10 within 12 hours.

Home visit is part of the antenatal care. Community health nurses make home visits to all
expectant mothers and special attention is given to those who default follow up and to high
risk mothers. The home visits are done at least four times during the gestational period - after
booking (before 28 weeks), within 28-31 weeks, within 32-35 weeks, within 36 weeks until
delivery. During these visits the medical personnel will assess the home environment and
sanitation. The nurse assesses the family size, nutritional status, personal hygiene, type of
water supply, solid waste disposal and sewerage system used. If there is a need to assist the
family by improving the physical environmental especially the sanitation, the Assistant
Health Environmental Officer from BAKAS program will be notified and further evaluation
is conducted by them.

Home visit bag

66
The expectant mother can choose place of delivery either to have home or hospital delivery.
However home delivery is an option only for WHITE coded expecting mothers only.
Community nurses as well staff nurses in health clinics are trained to conduct home delivery
and manage the intrapartum problems accordingly. They will resuscitate and care for the
cord. In home deliveries, a series of charted measurements using a partogram, are used to
assess the progress and recognize complications of labour. If any complications like
prolonged labour, antepartum haemorrhage, convulsions, mal-presentations, prolapse of cord,
etc. are detected the midwife or community nurse will refer the mother to the nearest
government hospital. All possible measures are taken to ensure clean and aseptic technique is
used during the delivery, and the mother and infant are free of injury.

Home delivery bag

Deliveries can also be done at Alternative Birth Centres (ABC). Approximately a third of the
population of Malaysia live in rural areas. Although most rural women now accept modern
health care but because of inaccessibility, beliefs and practices they may be reluctant to
deliver in hospitals. The ministry of health being cognizant of this and to ensure modern
medical care is provided low-risk birth centres called Alternative Birthing Centres (ABC) are
established. These centres are manned by staff nurses, and community nurses who are trained
to deliver babies and to identify problems early and refer women who develop complications
to the nearest hospital by ambulance.

67
 Pictures of an ABC taken from a ‘Klinik Desa’ in Perak

Post natal care

Post-partum care concerns with prevention, early diagnosis and treatment of complications of
mother and infant, including the prevention of vertical transmission of diseases from mother
to infant and if necessary referral of mother and infant.

All deliveries are notified to the nearest government health clinics accessible to the expecting
mothers. The public health nurses conduct the postnatal visits in the mother’s homes on the
1st, 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th, 15th and 20th postnatal days. On day 30 post-natal the
follow-up is done in the health clinic. However, frequent visits may be conducted where
necessitated by certain complications of the mother or the new-born. For example, for
mothers with hypertension or other complications, home visits are conducted on alternate
days until day 20. For new-born with jaundice, home visits are conducted daily.

During the home visits, history is taken to establish the status of the mother’s health and
wellbeing and when needed referral is done. The mother is asked questions concerning breast
tenderness, abdominal pain, foul smelling or excessive lochia, and difficulty in urination.
Physical examination of the mother is also done. The mother is examined for complications
like puerperal sepsis, secondary haemorrhage, urinary tract infections, mastitis etc. Pulse and

68
temperature is taken and fundal height measured and breasts examined. The nurses are also
on the lookout for signs of complications like breathing difficulty, redness and inflammation
of lower limbs, calf swelling and tenderness. If episiotomy was done, the mother is advised
on care of the stitches. If Caesarean section was done, the incision site is inspected for signs
of infection. The mother is also advised on her diet, personal and environmental hygiene,
early and exclusive breastfeeding, immunization, contraception and the resumption of sexual
activity, and postnatal exercises involving pelvic stretches of pelvic and abdominal muscles.
If relevant, the mothers are counselled on STD/HIV prevention and management

The new-born is also monitored and examined during the home visit. History concerning the
baby’s feeding habits and bowel movement and urination is taken. If necessary the nurses
observe the feeding and help the new mother with the effective breast feeding techniques.
The infant is inspected for jaundice outside in the sunlight or in a bright room and inspected
for yellowish discoloration of the skin. Then a routine neonatal examination is done, starting
from examination of the general appearance, baby’s length, head circumference, body weight
and plotted on a percentile chart, fontanelle, body temperature, umbilical cord, examination
of the lower limbs, genitalia and spine for spina-bifida. In particular, the new-born’s weight is
taken on day 6, 10 and 20 using portable baby weighing scale.

Maternal Death

Maternal death is defined as “the death of a woman while pregnant or within 42 days of the
termination of pregnancy, from any cause related to or aggravated by the pregnancy or its
management, but not from accidental or incidental causes”.

69
 Maternal Mortality Rate- Malaysia
12
10.8
10

8
8.5

6 5.8 MMR
4.7
4
2.8
2 2.1
1.6
1 0.8 0.4
0 0.2 0.2 0.3 0.3 0.3 0.3
1933 1938 1948 1953 1958 1963 1968 1973 1978 1983 1988 1993 1998 2003 2008 2010

Classification of Maternal Deaths

According to WHO, maternal deaths are classified into the following categories
 Direct Maternal death: Deaths resulting from obstetric complications of the pregnant
state (pregnancy, labour, and puerperium) as a result from interventions, omissions,
incorrect treatment or from a chain of events resulting from any of the above. In
Malaysia the common direct causes of maternal death are postpartum haemorrhage,
hypertension, and thromboembolism
 Indirect Maternal death: Deaths resulting from a previous existing disease, or disease
that developed during pregnancy which was not due to direct obstetric causes but
which was aggravated by the physiologic effects of pregnancy such as anaemia or
infections like malaria
 Fortuitous Maternal death: Deaths resulting from causes not related to or influenced
by pregnancy e.g. deaths from drowning and road accidents, where the pregnancy is
unlikely to have contributed significantly to the death, although it may be possible to
postulate a remote association

Confidential Enquiry on Maternal Death (CEMD)

The confidential enquiry on maternal death (CEMD) is a non-fault finding or punitive system
that was introduced in 1991. The CEMD process was designed to examine both the social and
medical causes of every maternal death and to review the roles of all personnel involved with

70
the purpose of identifying preventable factors and subsequently measures to be taken to
address the deficiencies.

The objective of CEMD is to learn lessons in order to save lives and to reduce preventable
maternal mortality. The advantages of CEMD is that it provides accurate statistics on
maternal mortality rates and its causes by providing evidence on the main problems which
will help highlight the key areas requiring recommendations not only for the health system
but also the community and subsequently produce guidelines to improve clinical outcomes.
Provision of an improved alternative birthing centres, improved facilities, better
communications and maintenance of home-based maternal health records and the use of
partogram for home deliveries are some of the advances as a result of the CEMD.

CEMD is multidisciplinary and is nationally owned. All local health care workers who
provided care to the deceased pregnant woman are required to complete a standardized
confidential form. The process is confidential and all names including that of the deceased
and the health care workers involved are removed from the report before assessment is done.
CEMD reports are discussed at district and state levels before submission to the national
committee which evaluates and assesses these reports and prepares the final report and
recommendations on each maternal death.

Family Planning Programme

The National Family Planning Programme was introduced during the First Malaysia Plan in
1966. The national family planning programme is developed to improve the standard of
living and promote social development towards creating productive employment
opportunities and reduce income disparities. The objective of the family planning services
and counselling is to improve the health and welfare of the family in general by educating the
population concerning the family planning programme. Besides ministry of health, the
National Population and Family Development Board (NPFDB) is the main agency that
provides family planning services. The ministry of health cooperates and collaborates with
the NPFDB to promote, monitor and evaluate the Family Planning Integration Programmes.
To increase the acceptance of family planning services by the community, these agencies

71
provide and promote information, education and communication activities by increasing
community involvement in family planning programmes. The programmes are evaluated by
monitoring the contraceptive prevalence rates, fertility rate and by surveys conducted by
NPFDB on specific topics such as adolescent sexuality, international migration and fertility.

However there are certain barriers to family planning programmes. Medical contraindications
and side effects to certain family planning methods are a major impediment, especially the
contraindication to oestrogen containing pills by some clients. Other barriers include limited
healthcare staffs, social and cultural, administrative and bureaucracy barriers.

Presently family planning services are provided in both the urban and rural clinics. The
objective of the services in the clinics is to ensure good health of both the mother and child,
enable healthy spacing of children in the family and decrease morbidity and mortality rates.
Family planning clinics offer family planning counselling and services, breast examination
and Pap Smear Test. Family planning counselling starts from the antenatal period itself.
During the antenatal period the mother is advised on the importance of planned pregnancy
and the various contraceptive measures available. Family planning services in Klinik
Kesihatan are targeted to women who are married and requests the service, women with
menstrual problem e.g. menorrhagia and women suffering from sexually transmitted disease
(STI) and other high risk mothers i.e. poor spacing between children (< 2 years), poor
obstetrics history like recurrent spontaneous abortion, postnatal haemorrhage, parity of 5 and
more, too young (< 15 years old) or too old ( > 40 years old), with medical conditions
(hypertension, diabetes, and cardiovascular diseases), infectious disease (HIV, AIDS, Hep B)
and others medical conditions e.g. psychiatric problems.

In the family planning clinics, the client is given a family planning card upon registration.
Depending on the medical eligibility after a risk assessment which involves examination of
the blood pressure, weight, full blood count and pelvic examination, the patient will be
advised and counselled on the suitable contraceptive method. Counselling will include the
correct technique and the possible side effects. All contraceptives besides the IUCD which is
partially subsidized are free of charge. IUCD when dispensed is inserted by trained doctors,
nurses and midwives. Women who choose to take contraceptives are advised to start using
the contraceptives immediately after the postnatal period, because although lactation does
confer some protection against conception, it cannot be depended upon.

72
Women on contraceptives will be followed up annually. This follow up is to ensure correct
technique, safety and compliance of the methods. During the follow up period physical
examination (height, weight, BMI and breast examination) and yearly Pap smear is done for
them. In the clinics the patients are also taught the method for breast self-examination. It is
important to note that this check-up is not only for women on contraceptives, but for any
women who is sexually active.

There are many different types of family planning methods available at Klinik Kesihatan. The
commonly available ones are

I. Hormonal method: Include Oral Contraceptive Pills (OCP) and Injection method.
Hormonal methods work by preventing ovulation, thickening the cervical mucus and
making it hostile to the sperms. Oral Contraceptive Pills are synthetic hormones and
are either Progesterone only pills or combined pills. Progesterone only pills are given
to mothers who are breastfeeding because progesterone only pills will not decrease
milk production. Examples of progesterone only pills are Noriday, Norethisterone etc.
Combined pills have a combination of oestrogen and progesterone and can be given to
almost everyone depending on the side effects. Examples of combined pill are
Marvelone, ethinylestradiol etc. The advantages of using OCP are that they are
relatively effective, help reduce menstrual pain and bleeding during menstruation
making the user less liable to be anaemic and protect against pelvic inflammatory
disease. However, there are certain disadvantages which include OCP’s are not
suitable for women age 35 and above, may reduce breast milk production, may delay
return to fertility state after stopping the pills and the need to take the pills daily.

The commonly used hormonal injections include Depocon (Norethisterone

Enenthate). Depending on the injection type, injections are given intramuscularly at 2
months interval for the first 4 doses and subsequently every 3 months. The first dose
is given during the first five days of a menstrual cycle. The advantages of hormonal
injections are that because it does not contain oestrogen it does not affect breast milk
production; it is appropriate for women who cannot use the OCPs; and is suitable for
woman age > 40 years old. The disadvantages of the hormonal injections are that it
takes time to restore the fertility state; menstrual irregularities which may continue for

73
 as long as 1 year after the last injection -interruption of the normal menstrual cycle to
eventual amenorrhea occurs in 50% of women within the first year; and the possibility
of weight gain and depression.

II. Mechanical Barrier: Include Intrauterine Contraceptive Device (IUCD) and

condoms. IUCD is a small soft T-shaped device with a nylon string attached. IUCD
works by preventing egg and sperm from meeting and stop a fertilized egg from
growing inside the uterus. The device is inserted through the cervix usually
immediately after menstruation has stopped. Depending on the type, one IUCD can be
used for 1–5 years. Although there are several types of IUCD, at present only the
copper type is available in Kelinik Kesihatan (this information is subject to change).
The advantages of using IUCD are that frequent visits are not necessary; no
disturbance in sexual activity; and previous fertility state returns soon after IUCD is
removed. However, the disadvantages are that it is not suitable for women exposed to
STDs; with history of ectopic pregnancy; heart valve disease; anaemia; severe
menstrual pain; allergy to copper; have vaginal bleeding; and have a history of
malignant disease of the genital tract.

Condoms prevent pregnancy by acting as a mechanical barrier to the passage of

semen into the vagina. The advantages of condom are that it is readily available and is
usually inexpensive; involves the male partner in the contraceptive choice (this in
some cases may be a disadvantage); effective to prevent both pregnancy and STDs;
and there is no need for check-up before use. The disadvantages of using a condom
are that it reduces pleasure; not suitable for those with latex allergy; condom breakage
and slippage decrease effectiveness; and oil-based lubricants may damage the
condom.

III. Other methods: other contraceptive method include natural methods which are
calendar use, cervical mucus monitoring by change of its characteristic and basal
body temperature.

74
B. CHILD HEALTH

Understanding that children are the most valuable asset which will determine the nation’s
future, the government provides continuous care and supervision to ensure the child is
healthy and is able to reach optimal development, and become an adult that is productive to
self, family, community and country. Child health service which is a part of the maternal and
child health programme started in the 1950’s in urban and suburban areas, it has now
expanded to all Klinik Kesihatan and Klinik Desa in the country.

90

80 78.4

70 68.9

60

50 48.5
Neonatal Mortality Rate
Infant Mortality Rate
40 39.4
Toddler Mortality Rate
32.2
30 29.5 30.1
25 23.8
20 21.4
19.3
16.4
14.2 13.1
10 11.1 10.4 10.3
8 8.5 6.8
6.8
5.8 6.5 6.6
4.2 3.1 3.7 3.9 4.4
1.4 2.1
0.9 0.8 0.6
0 0.5 0.4
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010

In an effort to improve child health and reduce infant mortality rates, the government of
Malaysia has a range of programmatic interventions. Programmes like Pro-poor policies,
Applied Food and Nutrition Programme (AFNP) and Development Programme for the Hard-
core Poor (PPRT) were developed to combat poverty. These programmes are developed to
reduce infant and child mortality by improving nutrition and reducing malnutrition and
nutritional deficiencies among young children and women of reproductive age. The ministry
of health ensures that trained health care workers are working in health centres and sub-
centres which provide specific child health services. The maternal child health services in the
ministry of health monitor the growth of the child to assess health and nutritional status for
early action or intervention if needed; oral rehydration therapy to manage childhood
diarrhoea; promote breastfeeding; nutrition surveillance (Food Basket Programme); National
ARI (Acute Respiratory Infection) programme to improve case management of ARI and

75
expanded programme of immunization (EPI) to reduce vaccine preventable child mortality
rates. Other programmes by the government to improve child health include the National Plan
of Action for Children to address issues of development, protection and participation of all
children in Malaysia, action plan for HIV/AIDS, school health program to give optimum
health care to pre-school, primary and secondary school children to encourage good health.
Baby-Friendly hospitals were implemented to create conducive environment in hospitals for
women who wish to breastfeed their child.

The objective of the child health service in the ministry of health is to

 reduce child mortality rates by reducing perinatal mortality
 infant mortality and under 5 mortality
 evaluate growth development and capabilities of children
 provide advice and support to mothers regarding child care and
 detect early signs of disabilities and high risk cases in order to get early referrals and
immediate treatment to reduce child morbidity.

These objectives are met by increasing the skills of the staffs (doctors and allied health
professionals alike) involved in child health care, by immunization programmes including
tracking cases of incomplete immunization and increasing the attendance for regular child
check-ups in clinic.

The services provided in the district health include care of the new-born, neonatal care and 0
to 6 year old child’s care. The table below shows the recommended visit schedule. Routine
activities in the child health services in Klinik Kesihatan include general examination, child
developmental and growth assessment, nutritional assessment as well as anthropometric
measurements and G6PD screening at birth to detect early childhood problems to enable
early, appropriate treatment and care to be given to reduce morbidity and mortality rates
amongst children. Depending on the needs and conditions, the scope of the services is ever
increasing. Programmes such as children with special needs and children with nutritional
deficiencies are examples of expanded programmes amidst the existing services. To meet the
demands of the child health services the technical knowledge and skillsof healthcare workers
have also improved.

76
A standard operating procedure is used as a guide for healthcare workers to provide efficient
and effective standardized level of service. M-CHAT (Modified Checklist for Autism in Toddlers)
is done twice, when the child is 18 months old and 3 or 4 years old. It is carried out during the clinic
visits. Home visit for high risk babies and pregnancies are part of the MCH programme,
however, such home visits occur mainly in the rural clinics as the huge workload in urban
clinics make it difficult to carry out such visits at times. The recommended frequency of the
home visits are at least 9 times for the first month. The first visit is done on post natal day one
followed by 2nd, 3rd, 4th, 6th, 8th, 10th, 15th, 20th post natal day. The clinic visits start when the
baby is 1 month old. However the home visits are conducted more frequently if the baby is at
risk for some medical problem e.g. jaundiced. During house visits the general examination
which includes general condition of the baby, feeding assessment, activity, body temperature,
colour, respiratory rate, eyes, presence of jaundice, umbilical cord, skin, urinary and bowel
output is done. Parents’ worries are allayed and queries answered and a developmental
checklist is completed. The mothers are advised on thermal protection, breastfeeding and
bonding, hygiene and cleanliness, skin and cord care and neonatal jaundice.

The anthropometric measurements which are taken to evaluate the growth development of the
child include
 Weight – measured on post-natal day 6, 10 and 20.
 Length or height – length is measured in supine position for child below 2 years old
and in standing position for children 2 years and above.
 BMI for age
 Head circumference – measured on every 3month until 3 years old to detect any
abnormality such as hydrocephalus or microcephalus.
 Chest circumference – measured on first visit and once for every 6 months until 2
years old. This is done to monitor the nutritional status of the child. In normal cases
after 6 months, the chest circumference should be greater than the head
circumference.

77
Age Frequency of visit
< 6 months Once a month
6 months -1 year Once every 2 months
1 – 2 years Once every 3 months
2 – 4 years Once every 6 months
4 – 6 years Once every 1 year
Table showing the recommended visits in the ministry of health clinics

78
Age Normal Development Stages
Months/ Gross motor Vision Hearing Speech Adaptive Behaviour
years (Fine motor) (Personal Social)
1 month  Rooting  Eyes do not Eyes move Cry Fixated and  Cry
 Grasp focus on the towards follow face  Smiles
 Moro view direction of
 Eye blinking sound
when expose to
light
3 months Move all Eyes follow Startles to Begins to have a Follow face Smiles
extremities moving objects loud noises soft voice and responsively
giggling
6 months  Control of  Focus vision on Respond to Vocalise da, ba Palmar grasp Eyes follow
head from objects sound movement of
lying to  Reaches out for objects
sitting toys
position
 Facing
downwards
9 months Sits without Follows distant Respond to Imitate sound da Transfers
support objects name da, ba ba objects from
calling one hand to
another
12 months Stands up Follows fast- Turn to the Say dada/mama Knock two Waves bye-bye
without support moving objects direction of without any objects with one
voice and meaning another
recognize
the people
18 months  Walks on See objects like an Understand  Say 3 words Scribble Able to follow
their own adult easy words with meaning spontaneously simple
 Able to follow instructions
simple
instruction
2 years  Walk well See objects like an Understand  Use simple  Build tower
 Running adult easy words phrases of 6 cubes
 Climbing  Able to  Open pages 1
stairs answer simple by 1
questions  Points to
pictures
 Independent
3 years  Use feet See objects like an Understand  Use simple  Build 10  Begins to
efficiently adult easy words phrases tower cubes socialize
 Jumping  Able to  Colour  Able to
 Climbing answer simple matching arrange
questions BOPU well

4 years  Skips on one Able to see Understand  Fictional story  Able to copy  Play with
foot alphabets at 6 easy words  Understand the symbol' others
 Goes down meter distance words such as X'  Share toys
stairs one feet hungry/up  Matches basic  Washing
per step shapes hands and
face by their
own

Table showing child development. Taken from Lissauer T. and Clayden G., Illustrated textbook of paediatrics,
second edition 2001, child development hearing and vision p23-28

79
Child Immunization Programme

National Immunisation Programme (NIP) started in the early 1950’s and the expanded
programme for immunization in 1989 was developed as a measure to implement the child
survival strategies which would lead to a reduction in morbidity, mortality and disability from
vaccine preventable diseases and establish immunity in the community, and subsequently
prevent occurrence of infectious disease epidemic or outbreak. Child immunization
programme was started in a phased and sustainable manner. At present the Ministry of Health
Malaysia has immunization programmes against ten major diseases in childhood. Smallpox
immunisation was introduced in the early 1950’s and dropped in 1980 following the global
eradication of the disease. DTP (against diphtheria, tetanus and pertussis) was introduced in
1958, followed by BCG in 1961, oral polio vaccine (OPV) in 1972, measles in 1982, rubella
in 1988 and Hepatitis B in 1989. In 2002, the Ministry of Health introduced Haemophilus
Influenza type B (Hib), and MMR (combination vaccine against measles, mumps and rubella)
to replace the measles and rubella vaccines.

Incidence of selected vaccine preventable diseases (per

100 000 population), 1988-2008

0.3 0.25

0.25
0.2

0.2
0.15
0.15
0.1
0.1

0.05
0.05

0 0
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Polio Whooping cough Neonatal tetanus ( 1000 LB) Diptheria

As a result of this programme, the incidences of vaccine preventable diseases have declined.
The incidence of pertussis, diphtheria and neonatal tetanus have been reported at less than 1
per 100,000 live births, and the incidence of Hepatitis B and Measles have dropped steadily

80
to 3.2 and 1.2 per 100,000 respectively in 2008. Malaysia was certified as polio-free country
by the World Health Organization on 29 October 2000.

Vaccines

Vaccines work by stimulating the body’s immune response. The immune system of a
vaccinated person produces appropriate defence mechanism to foreign bodies in vaccines
which are usually the harmless portion of an infectious agent. Immunity may vary from years
to life-long immunity.

There are numerous types of vaccines. Live attenuated vaccines contain weakened infectious
agent. When exposed to this type of vaccine the body immune system will remember the
agent and will be able to protect the individual in future exposures. Live attenuated vaccine
cannot be given to individuals with depressed immunity. Examples of this type of vaccine are
measles, mumps, rubella, varicella, influenza and rotavirus vaccines. Inactivated or killed
vaccines are vaccines containing killed agents which are incapable of replicating but are
intact enough to trigger the immune response. Example of this kind of vaccine is oral polio
and hepatitis A vaccine.

Because some bacterial diseases are caused by the toxin produced by the bacteria, toxoid
vaccines are made to inactivate the toxins. These vaccines are made using the weakened
version of the toxin called toxoid. Diphtheria and tetanus toxoid are examples of this kind of
vaccines.

Subunit vaccine contains only part of the virus or the bacteria. Pertussis vaccine is an
example of this kind of vaccine. Conjugate vaccine is prepared by attaching part of the outer
layer of the antigen to a carrier protein. Haemophilus influenza type b is an example of this
type of vaccine.

Table below shows the vaccines which are included in the ministry of health’s child
vaccination programme

 BCG vaccine: The Bacille Calmette-Guérin vaccine (BCG) is a live attenuated

strain of Mycobacterium bovis. It is administered through intra-dermal injections at
the left deltoid. A small lump at the injection site indicates that the vaccine is
effectively given. This vaccine is contraindicated in persons with symptomatic HIV

81
 infection where generalized infection may occur because of depressed immunity.
The common side effect is the occurrence of a local reaction, usually a papule, at
the site of vaccination within 2 to 6 weeks. Occasionally a discharging ulcer may
occur. This local reaction heals to leave a BCG scar of at least 4 mm in successful
vaccinations. BCG adenitis may also occur. The vaccine must be stored between 2
to 8 ̊ C.

 Diphtheria, Tetanus, Pertussis (DTP): DTP vaccine which is composed of

Diphtheria and Tetanus as toxoids and Pertussis as killed whole-cell bacterium is
given in a 0.5 ml dose intramuscularly. It is contraindicated in persons with history
of anaphylactic reaction to a previous dose. The common side effects are mild
fever, pain and redness at the site of the injection. Complications of DPT vaccine
can be sterile abscess, febrile convulsions and anaphylaxis. This vaccine should be
stored between 2 to 8 ̊ C, and should never be frozen. Since 2009, MOH has started
giving acellular Pertussis to baby less than 6 months due to lesser side effects and it
can be given to immunocompromised children.
 Polio Vaccine: two types are available: Inactiveted Polio vaccine (IPV) which is
killed vaccine hence no risk of live virus associated riks. And Oral Polio Vaccine
which is a live attenuated vaccine given as single dose of 2 drops although WHO
reports that three or more spaced soses provices protective inmmune response
against subsequent infections in endemic areas where one serotypes predominate. It
is contraindicated in patient with a recent history of diarrhoea and vomiting. There
is a risk of vaccine-associated paralytic polio (VAPP) due to OPV, which happens
in approximately two to four cases per one million children immunized. It is stored
between 2–8 ̊ C.
*at the moment Inactivated Polio vaccine (IPV) is only used in hospitals and not at
the district level and is only given routinely for immune-compromised children.
 Hepatitis B vaccine: It is a recombinant DNA or plasma-derived vaccine and is
given in a dose of 0.5ml intramuscularly to the outer mid-thigh for infants and outer
upper arm for children. This vaccine is contraindicated in people who experienced
anaphylactic reaction to a previous dose. The common side effects are local redness
at the site of injection and rarely anaphylactic reaction. This vaccine is stored
between 2 to 8 ̊ C, and should never be frozen.

82
  Haemophillus Influenza type b Vaccine (Hib): is a conjugate vaccine, given in a
dose of 0.5 ml intramuscularly in the outer mid-thigh for infants and outer upper
arm for children. It is contraindicated in people who experienced anaphylactic
reaction to a previous dose. The common side effects are redness, swelling, and
mild pain at the site of injection. It is stored between 2 to 8 ̊ C.

There is a change in the use of the vaccines in Klinik Keshihatan, instead of separately
vaccinating using DPT, polio and Haemophillus Influenza type b vaccine (Hib), a
pentavalent (combination of 5 vaccines) injection ‘D Tap’ (Pentaxim Trade name) is
being used.

 Measles, Mumps, And Rubella vaccine (MMR): this is a live-attenuated viral

vaccine, given in a dose of 0.5 ml subcutaneously injected on the outer mid-thigh or
outer upper arm. First dose is given at the age of 9 months and the second at the age
of 12 months. It is contraindicated in people who experienced severe reaction to a
previous dose, those who have congenital or acquired immune disorders and
pregnant individuals. The common side effects are fever, rash, and rarely temporary
arthritis in some young female children, parotid gland enlargement and very rarely
aseptic meningitis. This vaccine is stored between 2 to 8 ̊ C. The vaccine can be
stored for long period but not in a diluted form.

Age Year
Immunisation
0 1 2 3 5 6 9 12 18 21 7 13 13.5 15
BCG Dose 1
Hepatatis B Dose 1 Dose 2 Dose 3
DTaP Dose 1 Dose 2 Dose 3 Booster
Hib Dose 1 Dose 2 Dose 3 Booster
Polio (IPV) Dose 1 Dose 2 Dose 3 Booster

Measles Sabah
only
MMR Dose 1 Dose 2
MR Booster
DT Booster
HPV Dose Dose
Girls only 1 2
Tetanus Booster
JE (Sarawak) Dos2 1 Dose 2

83
Table showing the immunization schedule 2016 Malaysia

Cold Chain System and Storage of Vaccines

Vaccines can be damaged if not handled with care, if it expires and direct sunlight can cause
potential damage to all vaccines especially Polio, Measles and BCG. Freezing may damage
DPT and Tetanus Toxoid. Chemicals like disinfectant, antiseptic, spirits and detergents also
can damage the vaccines and if temperatures that do not abide by the rules set by the cold
chain system.

Cold chain system is a system of uninterrupted temperature controlled supply chain involving
the transport, distribution and storage of vaccine in potent conditions from manufacturing
until its utilization. The cold chain system comprises three major elements –

 Personnel - who use and maintain the equipment and provide the health service
 Equipment- for safe storage and transportation of vaccines and
 Procedures- to manage the programme and control distribution and use of the
vaccines.

All vaccines are sensitive biological substances that progressively lose their potency. Some
vaccines are sensitive to heat while others can be damaged by freezing. Each minute and
degree above or below the ideal temperature may shorten the vaccine's life.

Vaccines from manufacturers are transported by air to the supplier where they are stored.
These vaccines are later distributed to various states by air or land transport and stored in
integrated stores in the state health or district pharmacy. From here, the vaccines are then
distributed to the district health offices and health clinics. In the health clinics the vaccines
are stored in refrigerators where they are monitored twice a day and readings are recorded on
a chart to ensure that a safe temperature is maintained. This is done using a liquid
minimum/maximum thermometer which consists of 2 interconnected glass columns
containing a mercury-free liquid. Both maximum and minimum levels are recorded into a
book for monitoring purposes. Temperature should not exceed 8°C nor go below 2°C.
Maximum temperature is marked in red, minimum as green, and the current temperature as
blue.

84
Pictures showing vaccines stored in the klinik kesihatan and a minimax thermometer

Picture showing a chart used to monitor temperature of refrigerator storing vaccines

Most vaccines contain heat sensitive labels which are placed on the vaccine vials to register
cumulative heat exposure over time. It is in a form of a circle with a small square inside it. It

85
can be printed on a product label, attached to the cap of a vaccine vial or tube, or attached to
the neck of an ampoule. The combined effects of time and temperature cause the inner square
of will turn dark gradually and irreversibly from the effects of time and temperature. The
colour will change faster when the temperature gets higher. When the inner square is lighter
than the outer circle the vaccine is usable. When the colour of the inner square matches the
colour of the outer circle or when the colour of the inner square is darker than the outer circle,
the vaccine must be discarded.

Picture showing vaccine vial monitor

Vaccines are kept in their original packaging in the refrigerators in the Klinik Kesihatan and
Klinik Desa. The vaccines are stored in an orderly manner in the top shelf of the refrigerator.
New vaccines are placed on the left and old ones on the right and the order of use is from
right to left. Different types of vaccine are separated clearly from each other, with 1 to 2 cm
space between the rows of vaccines to permit aeration. Vaccines are never kept in the
freezers. Similarly diluters are never kept in the freezer because the bottles may break. Water
containers are kept in the lower compartments or in the refrigerator door shelf so that in the
event of a blackout, this will help to maintain the cold temperature of the refrigerator. This
will also help in reducing the rise in temperature when the refrigerator is being opened. Only

86
ice packs and water stored in bottles are allowed to be kept in the refrigerators used to stock
the vaccines. Food or drinks are not allowed because frequent refrigerator opening will affect
the optimal temperature required. The lower compartment is not used to stock the vaccines
because it is warmer compared to others parts of the refrigerator.

If there is an electricity interruption, the refrigerator storing the vaccines is never opened.
This can prevent 5oC increase of temperature up to 72 hours. If there is an electrical
disruption for more than 72 hours, the vaccines should be placed in another functioning
refrigerator. When transporting the vaccines the physical condition of the vaccine is
monitored and frequently inspected.

87
 CHAPTER 6: DISEASE PREVENTION AND CONTROL

There is a transition of disease burden from infectious, nutritional and perinatal diseases to
non-communicable diseases. This is more apparent in developing countries and Malaysia is
no exception. Although communicable diseases are still a cause of concern, the public health
focus has shifted to non-communicable disease burden. This is because Malaysia has made
remarkable progress in the control of communicable diseases. High population coverage with
safe water supply and sanitation, an effective child immunization programme, nutrition and
growth monitoring, harm-reduction strategies to curb the spread of HIV among drug users
and extensive coverage by the integrated primary health care system have contributed to the
higher quality of health. However, infectious diseases are still a threat, especially emerging
and re-emerging infectious diseases.

Non communicable diseases are illnesses which are not non transmissible among people.
The burden of non-communicable diseases in Malaysia is similar to that of a developed
nation. The economy of the country is better than it was during independence and is ever
improving. Due to the increase in income and behavioural change especially sedentary
lifestyle, stressors, increase in tobacco and alcohol consumption and unhealthy dietary habits
has resulted in the increase of non-communicable diseases. According to the report of the
National Strategic Plan for Non-Communicable Disease (NSPNCD) of the Ministry of Health
Malaysia there is an increase in the prevalence of hypertension, diabetes and obesity. The top
five leading burdens of diseases in Malaysia (DALY 2004) were Ischemic heart disease
followed by mental illness, cerebrovascular disease/stroke, road traffic injuries and cancers. It
is estimated that 68% of all mortality in 2008 were because of NCD. According to the WHO
the probability of dying from the four main NCD in Malaysia is about 20%. The adult risk
factors for NCD are current tobacco smoking, alcohol consumption, raised blood pressure
and obesity.

Communicable diseases can simply be defined as diseases that can be transmitted from one
person to another. The classic definition of communicable disease is “an illness due to a
specific infectious agent or its toxic products that arises through the transmission of that
agent or its product from an infected person, animal or reservoir to a susceptible host, either
directly or indirectly through an intermediate plant or animal host, vector or inanimate
environment”. Communicable diseases are caused by bacteria, virus, fungi, parasites and its

88
toxins. In 2007, the top five notifiable diseases were dengue fever, tuberculosis, food
poisoning, hand, foot and mouth disease (HFMD) and HIV/AIDS. In 2008 communicable
diseases and injury accounted for 20% and 12% respectively as the causes of premature death
in Malaysia.

Malaysia, with the support and help from the WHO has developed and strengthened the
health system and health policy to prevent and control NCD by risk factor prevention and
promotion of healthy life styles and control of communicable diseases like HIV/AIDS and
STIs, surveillance and response to outbreaks etc. Malaysia also collaborates with other
nations from the surrounding region to control and prevent emerging infectious diseases and
dengue, malaria etc.

Disease Control Division

The disease control division is under the public health division of the Ministry of Health
Malaysia. At the state level the objective of the unit is to

 To reduce the incidence of diseases and number of deaths caused by communicable

diseases, non-communicable diseases as well as environment- related diseases.
 prevent, control and reduce the incidence of communicable diseases caused by
unhygienic environment
 promote and provide healthcare access particularly in methods of prevention and
control of infectious diseases
 promote healthy life-style, a healthy, safe and hygienic work environment and
workplace, suitable preventive measures, immediate detection and treatment,
continuous monitoring and suitable rehabilitation services.
 supervise and monitor all cases that should be reported within 24 hours under the
Infectious Disease Act 1988
 carry out preventive measures so that the diseases do not jeopardize the health of the
public and become an epidemic
 and to break the chain of infection between the modes of transmission and
communicable diseases

89
 All this is done with the participation of members of the public and cooperation among
departments so as to build a healthy and caring society.

The activities of the unit is to

 reduce the incidence of disease and death due to vector borne disease
 reduce the incidence of tuberculosis and leprosy
 prevent the occurrence and spread of HIV and sexual transmitted diseases (STD)
 reduce the incidence of air and food borne diseases, acute respiratory infection (ARI)
and by means of vaccination and through the prevention of the entry of quarantinable
diseases such as plaque and yellow fever
 conduct laboratory services for the purpose of diagnosis and disease control
 reduce the incidence of disease and death caused by non-communicable diseases
 encourage and maintain excellent physical, mental and social health among workers
in all sectors
 encourage and maintain a healthy environment
 improve the health condition of the population and the environment in urban areas

At the district level the disease control unit prevents, control and reduces the incidence of
infectious diseases caused by unhygienic environmental conditions and encourages and assist
the community in the prevention and control of infectious disease in a continuous manner
through change of attitude and behaviour.

Medical Officer of Health

Senior Asst. Environment Health

Officer

AEHO - CDC AEHO- CDC AEHO - AEHO - AEHO -

(Surveillance) HIV/AIDS TB/Leprosy Operating room

Organization chart of unit at District Health office

90
The figure above shows the organization of the CDC unit at a district health office. The unit
is headed by the Medical officer of Health and assisted by the senior environmental health
officer (AEHO) who in turn supervises the public health assistants who are involved in
performing the general functions of the CDC, TB and Leprosy, HIV/AIDS and Inspectorate
section.

Program Strategies for infectious diseases

The strategies of the disease control unit includes applying appropriate control methods
which include elimination of reservoir, interruption of transmission, protection of susceptible
host, notification and legislation, and surveillance

There are 3 components of eradication and control

 Communicable aspect of disease control i.e. elimination of organism by

chemotherapy
 Non communicable aspect of disease control i.e. deformity care and prevention
through physiotherapy and surgery
 Eradication of socio economic problem i.e. rehabilitation and removal of social
stigma

The strategies may include breaking the chain of transmission using one or more of the
following elements

91
Elimination of reservoir - in cases where humans are the reservoir, all patients and carriers
are found and treated, and for zoonosis, the suspected hosts are elimination.
Early Diagnosis & Treatment - will help shorten the course of the illness and the period of
communicability
Isolation and Quarantine– isolation is the separation of infected persons or animals during
the period of communicability to prevent direct or indirect transmission of infectious agent
whereas quarantine is the limitation of the freedom of movement of contacts*, be it persons
or animals, which have been exposed a communicable disease. The process of quarantine is
usually for a period of time which is not longer than the longest usual incubation period.
*Contact is a person or animal that has been in contact with an infected person or animal or
a contaminated environment.

Personal Hygiene – health education and promotion on personal hygiene is imparted to limit
the spread of infectious diseases especially those transmitted by direct contact.
Cleaning – the process of removing infectious agents and organic matters from surfaces on
which infectious agent may find favourable conditions for survival or multiply is done in
certain cases.
Disinfection – is the process of killing infectious agents outside the body.
Interruption of transmission – is the process of changing essential components of man’s
environment to prevent or break transmission of the infectious agents
Control of Food-borne diseases – this is achieved by ensuring proper hand washing
techniques, adequate cooking, refrigeration, removal of contaminated food etc.
Control of water-borne diseases – this is done by chlorination of water
Control of vector-borne diseases – this is done by the destruction of specific vectors and
their breeding places.
Protection to susceptible host- protection of the susceptible host can be done by
immunization, both active and passive. Active immunity is the process of exposing the body
to an antigen in order to generate an adaptive immune response. This response may take
days/weeks to develop but it is usually long lasting or even lifelong. Passive immunity, on the
other hand, is the process of providing IgG antibodies to protect against infection. It gives
immediate, but short-lived protection usually several weeks to 3 or 4 months at the most. The

92
immunisation programmes of the MOH include childhood immunisation and immunisation to
high risk groups.
Health Education -is given to individuals and groups of people learn to promote, maintain or
restore health.
Notification and legislation – under the Prevention and Control of Infectious Diseases Act
1988, it is a requirement that all listed infectious diseases must be notified. This act states that
‘Every medical practitioner who treats or becomes aware of the existence of any infectious
disease in any premises shall, with the least practicable delay, give notice of the existence of
the infectious disease to the nearest Medical Officer of Health in the form prescribed by
regulations made under this Act.’ The general penalty under section 24 is ‘Any person guilty
of an offence under this Act for which no specific penalty is provided shall be liable on
conviction-

o in respect of a first offence, imprisonment for a term not exceeding two years or fine
or both;
o in respect of a second or subsequent offence, imprisonment not exceeding five years
or fine or both;
o in respect of a continuing offence, a further fine not exceeding two hundred ringgit for
every day during which such offence continues.’

Surveillance – there are numerous definitions of surveillance. According to the dictionary of

military and associated terms, United States department of Defence, 2005, which provides a
comprehensive definition which is “the on-going systematic collection, analysis and
interpretation of infectious disease data essential to the planning, implementation and
evaluation of health activities, closely integrated with the timely dissemination of data as
required by higher authority”. In short, surveillance is “information for action”. The
infectious disease surveillance system in Malaysia includes Mandatory notifiable disease
surveillance. At present this disease surveillance system requires the mandatory notification
of 26 infectious diseases (the number and type may change from time to time depending on
the situation) under the schedule 1 and 2 of the Prevention and Control of Infectious Disease
Act 1988 (PCID). The system involves manual reporting of infectious diseases using a
prescribed notification form as provided for under the Act. However, an electronic
Communicable Disease Control Information System (CDCIS) was implemented nationally
since 2001. In August 2002, Laboratory-based surveillance for infectious diseases was

93
introduced to complement the mandatory notifiable disease surveillance system. This system
entails the reporting of micro-organisms isolated in all public/private laboratories in Malaysia
to the relevant health authorities. Presently, 6 types of bacteria; V.cholerae, H. influenza,
Salmonella spp., S. typhi/paratyhpi, N. meningitides, and Leptospira are prioritized to be
monitored by the selected microbiology laboratories of the Ministry of Health. Clinical-based
surveillance is limited to specific infections either on a national basis (acute flaccid paralysis
and acute gastroenteritis) or on a sentinel site basis e.g. hand, foot and mouth disease. A more
comprehensive syndromic based surveillance (acute jaundice syndrome, acute neurological
syndrome, acute respiratory syndrome, acute dermatological syndrome, acute haemorrhagic
fever syndrome and acute gastroenteritis syndrome) was introduced in 2003. Community-
based surveillance involves the monitoring of rumours / events reports on infectious diseases
from the community and media both nationally and internationally. Officers performing this
task, monitor the international infectious disease trends using the internet and reports from
the international organizations e.g. the WHO.

Other agencies such as the Department of Veterinary Services and FOMENA Sdn. Bhd. also
conduct surveillance of certain infectious diseases. FOMEMA conducts surveillance of
certain infectious disease among foreign workers in Malaysia. Irrespective of which agency is
conducting the surveillance, all cases are reported to the Disease Control Division.
Notifications are sent to the District Health Office which then notifies the State Health
Department and finally to the National Disease Control Division, in the ministry of health.

Among the programmes used in the surveillance are

E-notifikasi (http://enotifikasi.moh.gov.my/Login.aspx),

Dengue (http://edengueuat.moh.gov.my:8081/Login.aspx),

MyTB (http://mytb.jknsabah.gov.my/auth/login) and

E-measles (http://emeasles.moh.gov.my/)

94
Responsibilities of CDC Unit (Under Section 2(1) Prevention & Control of Communicable
Disease Act 1988)

The main responsibility of the CDC unit is the prevention of infectious diseases in the
country. A Medical Officer of Health and Assistant Environmental Health Officer (@ health
inspector) are authorised officers elected by the Minister for the purpose of the Prevention
and Control of Communicable Disease Act (1988). An authorised officer is required to
maintain the confidentiality on every matter pertaining to his official duties under this act
except for the purpose of to serve the provision of this act. The officers are responsible in
ensuring that measures are in place to prevent the introduction of any infectious disease/s into
Malaysia from an infected area through all entry points into the country. They are authorised
to conduct medical examination and or collect samples from any person, animal or article on
board of a suspected vehicle coming into the country. If any part of the vehicle is unsanitary,
the authorized officer may order it to be disinfected to his/her satisfaction. If a person is
infected, the authorized officer may order such a person to be removed to a quarantine station
for isolation and observation or put under surveillance till the disease is no longer
communicable. The authorized officer is permitted to conduct the examination at any
reasonable time and the owner of the vehicle is required to comply.

The CDC unit is also responsible for the control and spread of infectious diseases using the
notification process. Every adult occupant of any house who is aware of the presence of a
notifiable disease, every medical practitioner who treats and is aware of the disease, any
person in charge of any boarding-house, and any police officer or village head who is aware
of the presence of the disease is required to notify the disease. The officer in the CDC unit
may order the contacts of the disease to undergo observation for such a time deemed fit or
until the contacts are discharged without being a threat to the public.

The officers are also responsible for ordering the corpse of a deceased person suspected to
have died due to an infectious disease to be appointed for examination if considered
necessary. The manner in which this corpse is buried or cremated must comply with the
standard guidelines.

The authorised officer is also responsible to disinfect and close premises which he or she
believes to be infected or is likely to lead to an outbreak or spread of infection. In cases of an
animal, if it cannot be disinfected, then it is exterminated. If buildings are contaminated by an
infectious disease, the authorized officer is responsible to prohibit any person from selling or

95
letting such building or any part without the authorized officer’s certification. In the case of a
vehicle which has been used to transport infected people, he/she may order such a vehicle to
be disinfected.

The authorized officer in the CDC unit has the responsibility to record every case of
communicable disease for research and to identify the disease status and prepare a daily,
weekly, monthly and/or yearly report. He/she has the responsibility to investigate all reported
cases immediately, obtain samples of blood, stools, sputum, vomitus, etc. when necessary and
locate the source of the infection and conduct disinfection if necessary and identify all
contacts of patients and conduct necessary precautions to prevent spread of the disease e.g.
vaccinate the patient contacts. The contacts and patients’ family members are also monitored
to prevent disease spread.

Other duties of the officers are to review all cases and data which are collected from
previously investigated cases; be a member of the health team during natural disaster
outbreaks; update graphs, maps and significant data on communicable diseases; and prepare
all prosecution reports and conduct prosecution with regards to communicable diseases. They
also carry out epidemiological research in prevention and control programs and educate the
public to enhance their knowledge of communicable diseases. For example, in a case of TB,
the Health Inspector (Assistant Environmental Health Officer) will visit the patient’s house
and workplaces for contact tracing and provide health education to the patient as well as to
his/her close contacts. Home visits are compulsory for defaulted cases. In cases of food and
water borne diseases, the officers will investigate reported cases and obtain data concerning
the disease, possible causes and location of disease spread. They will also visit the patient’s
house and workplaces for contact tracing and if necessary obtain samples such as faeces,
rectal swab, food or water for lab investigation and disinfect patient’s house or workplace.

Notification methods

Notifications can be made either by phone, fax, despatch or eNotifikasi. eNotifikasi was
launched on 2nd of January 2011 to replace eNotis/CDCIS. eNnotifikasi is available at the
following website http://enotifikasi.moh.gov.my/Login.aspx. eNotifikasiis used for specific
diseases (eDengue, National Aids Registry, MyTB, SM2(Measles)). The users for this system
are the Assistant Medical Record Officer (AMRO), Assistant Environmental Health Officer

96
(PPKP) at the district / state Level, Medical Officer, District Health Officer, Epidemiological
Health Officer and Officer at the Ministry Level.

97
 Receive notification by phone/fax/e-Notifikasi/notification form

Stamp the date and time receive on the notification form

Pass the form to District Health Office/ Assistant Environmental Health Officer

Register onto e-Notifikasi

Keep the form in the Investigation of communicable disease file

Prepare investigation form and equipment according to the type of disease

Obtain detailed information

Record data into case registration programme

Send preliminary report to State Health

Department
Complete the case investigation form. &visit
patient’shouse
Control & preventive
measures
Record and file up the activities carried out

File the case investigation form

Checking, analysis and signature by District Health

Officer
Send the report to the State Health
Department

Keep a copy of report in the file

Notification flow chart of communicable diseases under prevention and control of communicable disease act
1998

As shown in flow chart above, when a health inspector (Assistant Environmental Health
Officer) is notified via phone, email (e-Notifikasi) or notification form regarding a
communicable disease, he/she first stamps and registers the time and date the forms are
received and passes it on to the assistant environmental health officer who registers it into e-
notifikasi and keeps a record of the form in the investigation file under communicable
diseases.The health officer then prepares the investigation forms and equipment’s required
for the specific type of disease. He/she is also responsible in sending a report to the state
health department. He and the team may visit the patient’s house and implement the
necessary prevention and control methods to stop further spread of the disease amongst the

98
contacts. He/she then records and files the investigational activities carried out. He/she also
analyses the data and again sends a copy of the final report to the state health department.

Receive notification by phone/fax/e-notifikasi/notification form

Stamp the date and time received onto the notification form

Pass the form to District Health Office/Assistant Environmental Health Officer

Register onto e-notifikasi

Keep the form in the investigation of communicable disease file

Prepare investigation form and equipment according to the type of disease

Obtain detailed information

Flow chart showing the surveillance of selected infectious diseases in foreign workers in Malaysia is being done
by FOMENA

The figure above shows the process of surveillance of infectious diseases conducted at the
district level amongst foreign workers in Malaysia.

99
Notification by Phone followed by written Written notification within one week after
notification (within 24 hours) Diagnosis

 Dengue fever/ Dengue haemorrhagic fever  Acute viral hepatitis A/B/C/others

 Yellow fever  Acquired immune deficiency syndrome
 Diphtheria (AIDS)/Human immunodeficiency virus (HIV)
 Ebola infection
 Food poisoning (Acute Gastroenteritis)  Chancroid
 Cholera  Dysentery
 Plague  Food poisoning
 Acute Poliomyelitis  Gonorrhoea
 Rabies  Hand, foot and mouth disease
 Influenza  Leprosy
 MERS-CoV  Leptospirosis
 Zika  Malaria
 Measles
 Relapsing fever
 Syphilis
 Typhus
 Tetanus
 Tuberculosis
 Typhoid
 Viral encephalitis
 Whooping cough
 Any other life-threatening microbial infection
List of diseases that must be notified to nearest health office

Notification of communicable diseases to the CDC unit in the district health office by the
health care personnel is mandatory. The list of diseases in table is mandatory to be notified
within the mentioned time frame. Other diseases which require notification include
Brucellosis, Melioidosis and Chikungunya.

100
Selected Ministry of Health Malaysia Programmes managed by the CDC

Common Terminologies in Disease Transmission

Infection is said to have occurred if an infectious agent has entered and established itself in a host.

Infectivity is the ability of an agent to invade and multiply in a host.

Pathogenicity is the ability to produce clinically apparent illness.

Virulence is the proportion of clinical cases resulting in severe clinical manifestation. Virulence may
depend on dose, route of infection and host factors such as age or race.

Immunogenicity is the ability to produce specific immunity, primarily humoral, cellular immunity, or a
mixture of both in the host.

A carrier is a person without apparent disease who is capable of transmitting the agent to others;
carriers may be asymptomatic, i.e. who never show symptoms during the time they are infected.
Incubatory or convalescent carriers are capable of transmission before or after they are clinically ill.

Chronic carrier is one who harbours an agent for an extended time following the initial infection.

Generation time is the period between the receipt of infection by the host and the maximal
communicability of the host.

Incubation time is the time interval between the receipt of infection and the onset of illness.

Herd immunity is the resistance of a community to a disease. Is not necessary to achieve 100 percent
immunity in a population in order to halt an epidemic or control a disease.

1. Polio Eradication Programme

The global eradication of poliomyelitis is a public health effort to eliminate all cases of
poliomyelitis (polio) infection around the world. The global effort, begun in 1998 and led by
the World Health Organization (WHO), UNICEF and the Rotary Foundation, has reduced the
number of annual diagnosed cases from the hundreds of thousands to 291 in 2012 – a 99.9%
reduction.

101
Strategy

The most important step in eradication of polio is interruption of endemic transmission of

poliovirus. Stopping polio transmission has been pursued through a combination of routine
immunization, supplementary immunization campaigns and surveillance of possible
outbreaks. The four key strategies outlined by the World Health Organization for stopping
polio transmission are:

1. High infant immunization coverage with four doses of oral polio vaccine (OPV) in the
first year of life in developing and endemic countries, and routine immunization with
OPV and/or IPV elsewhere.

2. Organization of “National immunization days” to provide supplementary doses of oral

polio vaccine to all children less than five years of age.

3. Active surveillance for wild poliovirus through reporting and laboratory testing of all
cases of acute flaccid paralysis among children less than fifteen years of age.

4. Targeted “mop-up” campaigns once wild poliovirus transmission is limited to a

specific focal area.

Surveillance Acute Flaccid Paralysis

The last major outbreak of polio in Malaysia was in 1977 with a reported 121 cases including
4 fatalities. Since the introduction of the national polio vaccination programme in 1972 the
situation has improved dramatically. The last case of indigenous wild poliovirus infection
(clinically confirmed) was in 1984. Since then until 1992 there were no further cases
detected. There was improved surveillance with an active search for polio cases especially
among the high risk population groups.

The real risk of important was recognized with the re-emergence of the disease in 1992. This
was indeed a wake-up call for Malaysia and also for many other polio-free countries to
realize this real threat. On further epidemiological investigation and genomic sequencing of
the virus it was confirmed to have been an imported strain.

In 1998, the World Health Assembly committed WHO to eradicate polio from the world by
the year 2000. This would eventually turn out to be the largest global public health disease
initiative ever embarked. Later in the same year the Regional Committee for the Western

102
Pacific endorsed the global commitment but added an accelerated time-frame from the
Region with an eradication target by 1995.

Malaysia initiated a formal national Acute Flaccid Paralysis (AFP) surveillance in 1993
which together with high polio vaccination coverage and an accredited functional laboratory
support formed the core strategies in combating polio.

2. Measles Elimination Programme

There is an effective and enhanced surveillance programme with the integration of

epidemiological and laboratory informationin place. Routinely two doses of MMR vaccine is
given to children. All suspected measles cases are confirmed by laboratory analysis and all
measles outbreaks are investigated and managed.

Measles is one of the major childhood killer before the introduction of its vaccine. And
World Health Organization (WHO) estimates that 130 million children below 6 years die due
to measles annually. Since the introduction of measles vaccine in 1964, the morbidity and
mortality due to measles have been reduced drastically. Measles vaccination was included in
the Expanded Program for Immunization (EPI) in 1974. Since then, coverage of measles
vaccination climbed steadily in all regions throughout the year 1980s.

In 1980s, after the success of smallpox eradication, some scientist and public health officials
have considered of global effort to eradicate measles. Since 1990’s strategies have been
planned and implemented in many developing countries to eliminate and eradicate measles.
Three regions of the World Health Organization that targeted elimination by 2000s are; in
1994, the American Region targeted elimination by 2000, in 1997, the Eastern Mediterranean
targeted elimination by 2010 and in 1998, the European Region targeted elimination by 2007.
In 2005, WHO for the Western Pacific targeted elimination by 2012.

As we have succeeded in controlling measles occurrence at low level, the Ministry of Health
in February 2003 decided to initiate measles elimination in Malaysia starting in 2004.
Following this decision, vaccination and surveillance strategies have been reviewed and
changed to achieve the elimination goals and objectives.

103
 Specific objectives of elimination initiative are to

 maintain the number of susceptible individuals below the critical number required to
sustain transmission of the virus

 eliminate measles by year 2010

 achieve zero measles mortality

Strategies

I. Vaccination strategies
 routine two dose MMR vaccine given to children.

II. Surveillance strategies

 enhancing measles surveillance with integration of epidemiological and laboratory
information.

III. Laboratory strategies

 laboratory confirmation should be done on all suspect measles cases.

IV. Response to outbreak

 all measles outbreaks will be carefully investigated

V. Case management
 improving the management of every measles case

VI. Training

3. Germ buster

This programme is concerned with promoting food safety and prevention of food poisoning
among the school children by educating them about proper hand washing techniques and
conducting quizzes and interactive games

4. TB national programme

DOTS (Directly Observed Treatment Short course) is the daily direct observation of patient
consuming TB medications by nurses to ensure compliance. Tuberculosis Control
Programme has been in place since 1961 as a vertical programme where Pusat Tibi Negara is
the main referral centre for Tuberculosis. In 1995, it was integrated into the Malaysian public
health system where the main control activities are being expanded into the peripheral health
clinics as well as the hospitals. This has proven to be a better managerial and control strategy

104
since all health officers in the districts are responsible for every TB case registered at their
respective areas. The integration of TB control programme in the public health sector has
contributes towards a declining trend in the country TB incidence, prevalence and mortality
from 1995.

The 2015 global targets for reduction in disease burden as per United Nation Millenium
Development Goal (MDG) Target 6.c is to halt and begin to reverse the incidence of TB by
2015. Targets linked to the MDGs and endorsed by Stop TB Partnership are to reduce
prevalence of and death due to TB by 50% compared with a baseline of 1990 by 2015 and to
eliminate TB as a public health problem by 2050.

In 1990 the incidence rate of TB was 127 cases per 100,000 population and 82 cases per
100,000 population in 2010. The prevalence rate was 227 cases per 100,000 population in
1990 and 107 cases per 100,000 population in 2010. The mortality rate in 1990 was 26 cases
per 100,000 population and 8.5 cases per 100,000 population in 2010. In order to achieve
MDGs Target 6.c, Malaysia must endeavour to reduce the incidence rate by at least 5%
annually from 2011 onward to achieve an incidence rate of 63 cases per 100,000 population
by year 2015.

The National Strategic Plan (NSP) provides a reference for actions to be taken in line
with 6 strategies:

 Strengthening components of health system

 Enhancing case detection

 Delivering, enhancing and expanding high-quality TB treatment

 Empowering people with TB and the community

 Limiting people from contracting TB and

 Promoting TB Centred research.

105
The National Tuberculosis Control Programme (NTBCP) include the following

i. Early case detection by screening of high risk groups and symptomatic cases at all
hospitals and health centres
ii. Mandatory TB screening of all foreign workers
iii. Directly observed therapy short course (DOTS) implementation at all treatment
centres
iv. Contact and defaulter tracing
v. Health education activities and
vi. Collaboration with other government and non-government agencies.

4. Food Poisoning

Food poisoning is considered when two or more cases of food poisoning are found due to the
same food source during the exposure period. Common causative organisms include S.
aureus, E. coli, Bacillus cereus, Salmonella sp, Campylobacter sp. A food premise can be
closed using the CDC Act 1988 or Food Act 1983. The food premise can be closed
indefinitely until the CDC Unit is satisfied that the food premise is safe for operations again.
Food act is used when the premise is dirty although no cases have been reported. The premise
can be closed for 14 days only, but may be extended for another 14 days if deemed necessary.

5. Typhoid and Paratyphoid

An outbreak is defined as an increase in cases at one point of time in one location compared
to the expected based on monthly median for the previous five years, or moving median of
previous five weeks. The outbreak is declared over when there are no new cases reported in
42 days (twice the incubation period) from onset of the last case. The common causative
organisms are Salmonella typhi and Salmonella paratyphi. Cases of typhoid or paratyphoid
must be notified by phone within 24 hours or by writing within one week. Public health
management is through active and passive case detection, investigation of notified cases,
contact tracing, food sampling, toilet disinfection, health education, vaccination using vaccine
Typhim vi (capsular polysaccharide) or Ty21a (oral, enteric-coated live attenuated). Cases
are followed-up and if stool culture is still positive after 12 months the case is considered as a

106
chronic carrier. Cases are only allowed to handle food if three consecutive monthly stool
cultures are negative.

6. Leptospirosis
Leptospirosis is caused by Spirochaetales (Leptospira). It is has a seasonal variations, cases
increase with the onset of the rainy season and declines as the rainfall recedes. It is
aggravated by increase in reservoir (natural rodent and non-rodent reservoir hosts), flooding,
drainage congestion, animal-human interface (i.e. exposure from occupational or recreational
activities without proper protection) and human host risk factors (chronic disease, open skin
wounds). Leptospirosis is transmitted is acquired from contact with contaminated water and
soil and ingestion of contaminated water.

High risk groups include search and rescue workers in high risk environment, disaster relief
workers (during floods), those who are involved with outdoor/recreational activities,
travelers, and people with chronic disease and open skin wounds

All probable and confirmed cases must be notified to the nearest District Health Office within
one week of the date of diagnosis.
Treatment is by antibiotic
- Severe: High doses of IV penicillin (2M units 6 hourly for 5-7 days)
- Less severe: Doxycycline (2 mg/kg up to 100mg 12 hourly for 5-7 days), tetracycline,
ampicillin or amoxicillin
- Third generation cephalosporin (ceftriaxone and cefotaxime) and quinolones

Monitoring is by surveillance. Leptospirosis is made as a notifiable disease in Malaysia under

the Prevention and Control of Communicable diseases Act 1988 since 2010. Surveillance
includes hospital-based surveillance, sero-surveillance (laboratory based surveillance using).
Example, MAT may give an indication of the prevalence of leptospirosis in an area and
active surveillance (especially to determine the incidence of leptospirosis)

Outbreak is considered when more than one probable or confirmed cases of leptospirosis with
an epidemiological link within one incubation period. Investigation and control measures are
taken wherever possible. During an outbreak, the District Health Office also investigates
clinical cases. The MOH notifies the National Crisis Preparedness and Response Centre
(SPRC) by phone or text/sms to an on-call surveillance officer. All preliminary outbreak

107
reports are sent to the CPRC, disease Control Division by e-mail, text/sms and fax. A final
report is produced after one month the outbreak ends and sent to CPRC, Disease Control
Division.

Prevention and control is targeted at

 the infection source
 the route of transmission between the infection source and the human host
 prompt and proper treatment of infection
 health education
 risk assessment of possible contaminated water sources/bodies
 alert public or users regarding the hazards of possible contaminated areas
 advise public to keep their homes and premises free from rodents
 advise people to vaccinate their pets against leptospirosis
 promote cleanliness at the recreational areas, food premises as well as housing area
 promote interagency collaboration such as with local authorities, Wildlife Department
(PERHILITAN), Department of Veterinary Services (JPV), National Training Service
Department (JLKN) etc. to maintain cleanliness in the respective environmental
settings, especially rodent control.

7. Leprosy

Leprosy is one of the oldest diseases of mankind. It was first described in 600 BC in India by
a surgeon Sushruta and referred to it a Kushtha meaning eating away. Like control of any
communicable disease it is based on the following factors

 Identify and attack the causative organisms

 Eliminate the adverse environmental factors
 Identify and correct the host factors Leprosy control

Primary prevention tool is not yet available to prevention of leprosy. The principles of
leprosy control is

 Case finding
 Treatment
 Case holding
 Deformity care and prevention
 Rehabilitation
 Health education

108
 For successful implementation of these principles, components like monitoring and
evaluation, training and research are important.

Case finding

 Active case finding – by screening of general population, schools, industries, hospital

inpatients, and family contacts of index cases
 Passive case detection – through mass education thus promoting voluntary reporting,
and screening of outpatients in hospitals

Treatment involves multidrug therapy. Patient’s regularity in attending the clinic and their
compliance regarding intake of self-administered dose is verified. Deformity care and
prevention is important because of its socioeconomic implications. Traditional style of
sheltered homes, asylums for vocational rehabilitation isolates the patients from their natural
environment is no longer practiced and community based rehabilitation is favored. Health
education is actively conducted to increase awareness of scientific aspects of leprosy,
encourage self-reporting, improve treatment compliance and to overcome social stigma

Outbreak Management at the District Level

The following is an outline of the steps taken by the CDC unit in cases of an outbreak
investigation at the district level

I. Verify the diagnosis

II. Confirm the existence of an outbreak

III. Identify affected persons and their characteristics

IV. Define and investigate population at risk

V. Formulate a hypothesis as to the source and spread of the outbreak

VI. Containment of an outbreak

VII. Manage cases

VIII. Implement control measures to prevent spread
IX. Conduct on-going disease surveillance
X. Prepare a report

109
 Receive information about outbreak

Mobilize ‘Bilik Gerakan’

Receive notification and case investigation

Send preliminary report
(only for food poisoning) to
State Health Department
Control and preventive measures during outbreak
Send daily report to the
State Health Department
Data analysis

Outbreak report

Record and filing

Flow chart showing the actions taken during food poisoning outbreak in a district health office

Once the district health office receives notification of a food poisoning outbreak from the
hospital /clinic/ other agency, rapid assessment team will verify the case. Then the rapid
response team from district health office will conduct the case investigation of the suspected
premise. Sampling of the raw material are made and if necessary the premise is closed .The
health inspector (Assistant Environmental Health Officer) will send a preliminary report on
the first day of receiving the notification of an outbreak followed by daily reports of the
investigation and appropriate preventive measures done to contain the outbreak. Data analysis
of the outbreak incident is done. An outbreak report is prepared and subsequently the report
is recorded, filed and submit to State Health Department.

110
 CHAPTER 7: SELECTED CDC PROGRAMMES

A. TUBERCULOSIS
Tuberculosis (TB) is an infectious disease caused by mycobacterium tuberculosis. Although
TB can affect any parts of the body, lungs are the most common site. The transmission is
usually by airborne i.e. it spreads from person to person through the droplets from the throat
and lungs of an infected person when they cough, sneeze, talk and spit resulting in the bacilli
propelling into the air. Pulmonary TB (PTB) and laryngeal TB are considered infectious
whereas Extra Pulmonary TB (EPTB) is not. TB can be cured by in most cases using a
cocktail of but if left untreated, the disease can be fatal. Generally TB treatment is 6 months
except for TB of the bone including spine and joints where the treatment can take longer,
more so in cases of TB meningitis. The diagnosis of PTB is made clinically supported by
imaging and laboratory tests. Confirmation is made by isolation of the Mycobacterium
tuberculosis from clinical samples. The disease is strongly linked to poverty and poor living
conditions, often striking the vulnerable and the marginalized groups.

The burden of TB is high in South East Asia (29%) and Africa (27%). It has been reported
that India and China account for 26 and 27% respectively of TB cases in South East Asia.
The Western Pacific Regions account for 19% of the cases. The African region has 24% of
the world’s cases and the highest rates of cases and deaths per capita. There are about 9
million new cases of TB with 1.5 million TB related mortality annually. TB rank 7 th as a
global cause of death and TB is the third most common cause of death among women of the
child bearing age. More than half a million women die of TB each year. In 2009, 10 million
children worldwide were orphaned because of death of a parent due to TB. Because TB is an
airborne infectious disease, children who are in close contact with afflicted parents and
family members are high risk of infection and subsequently death. It is estimated that 1.1
million HIV associated TB cases with 430,000 million deaths reported. Almost 80% of all
TB/HIV cases are in Africa. TB is the leading cause of death in people living with HIV, it is
estimated that a quarter of people living with HIV die due to TB. This is unfortunate
considering that these deaths occurring among people living with HIV are preventable by
simply treating the TB co-infection.

111
According to the WHO Global Tuberculosis Report 2013, although new cases of TB has been
falling at a rate of 2% each year and the mortality rate has similarly been declining but the
global burden of TB remains enormous. Although 56 million people have been successfully
treated for TB, saving 22 million lives but 4 million people fail to get access to TB treatment
each year although it is affordable. Resistance to TB drugs is another important problem in
the fight against TB. Each year half a million people become ill with multidrug-resistant TB
(MDR-TB). Despite the important control programmes TB is now re-emerging in many parts
of the world.

Figure showing TB incidence rates, 2011. Taken from WHO Global Tuberculosis Report 2012.

WHO response to Tuberculosis

As a TB control measure, the WHO employed a Stop TB strategy to reduce the global burden
of TB in 2015. The objectives of the Stop TB strategy includes to

 achieve universal access to high quality care for all people with TB
 reduce human suffering and socioeconomic burden associated with TB
 protect vulnerable population from TB, TB/HIV and drug resistant TB
 support the development of new tools and enable their timely and effective use
 protect and promote human rights in TB prevention, care and control

112
The targets of the Stop TB strategy include the MDG 6, target 6c i.e. to halt and begin to
reverse the incidence of TB by 2015 and to reduce prevalence of and deaths due to TB by
50% in 2015 compared with a baseline of 1990 and to eliminate TB (<1 case per million
population) by 2050.

The Millennium Development Goal (MDG) 6 deals with Tuberculosis in addition to

HIV/AIDS and malaria. The specific target set by the UN for each country to achieve the
MDG on TB is to

 reduce the incidence, prevalence and death rate by half by 2015

 ensure a 85% rate of cure among the newly detected smear-positive cases
 ensure that 100% of smear-positive cases are on DOTS by 2005 and
 detect at least 70% of estimated smear-positive cases.

The components of the Stop TB Strategy include

 to expand and enhance high quality DOTS

 secure political commitment and adequate and sustained financing
 early case detection and diagnosis
 supervised standardized treatment
 effective drug supply and management
 monitor and evaluate performance and impact
 address the problem of TB-HIV, MDR-TB and the needs of the poor and vulnerable
and marginalized groups
 scale up collaborative TB/HIV activities
 scale up prevention and management of MDR-TB
 address the needs of TB contacts, and the poor and vulnerable populations
 contribute to health systems strengthening based on primary health care
 improve health policies, human resource development, financing, supplies,
service delivery and information
 strengthen infection control
 upgrade laboratory networks and implement practical approach to lung health
 intersectoral collaboration especially on social determinants of health

113
  engage all health care providers
 involvement of all public, voluntary, corporate and private providers
 use of international standards for tuberculosis care
 empower people inflicted with TB and communities through partnership and
 pursue advocacy, communication and social mobilization
 foster community participation
 use of patients charter of tuberculosis care
 enable and promote research
 conduct programme based operational research
 research on new diagnostic, drugs and vaccines

The Sustainable Development Goals (SDG) under the goal 3 targets to end the epidemics of
AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-
borne diseases and other communicable diseases by the year 2030.

With the vision of a world free of TB, means of zero death, disease and suffering due to TB
WHO has implemented The End TB Strategy program with the aim to end the global
tuberculosis epidemic.

In comparison to 2015, the SDG target to reduce the number of TB deaths by 90%, reduce
TB incidence rate by 80% and 0% of TB-affected families facing catastrophic cost due to TB
by the year 2030. Whereas the End TB strategy targets to reduce the number of TB deaths by
95%, reduce TB incidence rate by 90% and 0% of TB-affected families facing catastrophic
cost due to TB by the year 2030.

The principles of the End TB strategy program include:

 Government stewardship and accountability, with monitoring and evaluation.

 Strong coalition with civil society organizations and communities.
 Protection and promotion of human rights, ethics and equity.
 Adaptation of the strategy and targets at country level, with global collaboration

114
The pillars and components of the End Tb strategy program include:

Pillar 1: Integrated, patient-centred care and prevention: Focuses on early detection, treatment
and prevention for all TB patients including children and aims to ensure that all TB patients
not only have equal, unhindered access to affordable services, but also engage in their care.
The component of pillar 1 as follows:

o Early diagnosis of tuberculosis including universal drug-susceptibility testing,

and systematic screening of contacts and high-risk groups.
o Treatment of all people with tuberculosis including drug-resistant tuberculosis,
and patient support.
o Collaborative tuberculosis/HIV activities, and management of co-morbidities.
o Preventive treatment of persons at high risk, and vaccination against
tuberculosis.

Pillar 2: Bold policies and supportive systems: Strengthens health and social sector policies
and systems to prevent and end TB; Supports implementation of universal health coverage,
social protection, and strengthened regulatory frameworks and addresses the social
determinants of TB and tackles TB among vulnerable groups such as the very poor, people
living with HIV, migrants, refugees and prisoners. The components of pillar 2 include:
o Political commitment with adequate resources for tuberculosis care and
prevention.
o Engagement of communities, civil society organizations, and public and
private care providers.
o Universal health coverage policy, and regulatory frameworks for case
notification, vital registration, quality and rational use of medicines, and
infection control.
o Social protection, poverty alleviation and actions on other determinants of
tuberculosis.

Pillar 3: Intensified research and innovation: Aims to intensify research from the
development of new tools to their adoption and effective rollout in countries; pursues
operational research for the design, implementation, and scaling-up of innovations and calls
for an urgent boost in research investments, so that new tools are developed, and made

115
rapidly available and widely accessible in the next decade. The components of pillar 3
include:
o Discovery, development and rapid uptake of new tools, interventions and
strategies.
o Research to optimize implementation and impact, and promote innovations.

Moving forward to the 2035 targets requires the ensured availability of new tools from the
research pipeline, in particular:

• Better diagnostics, including new point-ofcare tests;

• Safer, easier and shorter treatment regimens;

• Safer and more effective treatment for latent TB infection;

• Effective pre- and post-exposure vaccines.

116
The indicators used in monitoring TB are

number of TB cases with positive sputum

TB sputum convert to negative sputum after two months
X 100%
conversion rate =
(target 85%) number of TB cases with positive sputum
eligible for analysis

number of cured sputum positive TB cases in a

TB cure rate (target year
85%) X 100%
=
number of registered sputum positive TB cases
in the same period

number of successfully treated TB cases in a

TB treatment year treatment
success (cure & X 100%
=
completed
treatment) rate number of notified TB cases (all forms) in the
(target 85%) same period

number of TB deaths in a year

TB mortality rate
(target ≤5 in X 100,000
=
100,000 population)
estimated mid-year population in the same
period

TB in Malaysia

In Malaysia, the incidence and prevalence of tuberculosis was reported at 80 and 101 per
100,000 people respectively in 2012. The mortality due to TB was reported as 5.4 per
100,000. There were 21,851 notified new cases and 75 per 100,000 population relapse cases.
Case detection was 93% in 2012. Pulmonary TB is the most common form of TB reported in
Malaysia but Extra Pulmonary TB is also on the rise. Most of the cases are aged between 21
to 60 years old and almost 14% of the cases are foreigners. In 2013 there was 73% smear

117
positive new pulmonary cases. There were 13,311 smear positive cases whereas 4,993 smear
negative or unknown cases reported and 2,945 extra pulmonary and 602 relapse cases. MDR-
TB cultures have increased from 0.3% in 2005 to 1.3% of all Acid-Fast Bacillus cultures
positive for MDR-TB. Sabah followed by Selangor, Sarawak, Johor and Kuala Lumpur
reported the highest prevalence of TB cases.

The risk groups for TB include close TB contacts, immune-compromised patients, substance
abuses, cigarette smokers and poverty. Most PTB active patients present with history of
productive cough, haemoptysis and chest pain along with other non-specific symptoms
including loss of appetite, weight loss, fever, night sweats and fatigue.

New TB Cases
25000

20000

15000

cases
10000

5000

0
2005 2006 2007 2008 2009 2010 2011

Figures showing TB cases reported from 2005 to 2011

118
 Incidence of tuberculosis (per 100 000
20000 68
17506
18000 66.6 16665
15429 66
16000 15057
64.7 14115 64.7 14389
14000 12691 64
63.6
10944 10873 1142063.2 11708 63.1
12000 10734
62
61.2 61.6
10000 61
60.3 60
8000 59.8
58.7
6000 58
4000
56
2000
0 54
1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008
No of cases Incidence rate / 100 000

History of TB in Malaysia

Like most developing countries, in the early 1940’s and 50’s, TB was a major cause of
morbidity and it was the number one cause of death in Malaysia. Patients with TB were
admitted to the sanatoriums located in various parts of the country. Although in the late
1950’s TB chemotherapy became available, it was still a major cause of morbidity and
mortality. Being cognizant of the burden of TB, the Malaysian government launched its
National TB Control Programme (NTP) in 1961. The National TB Centre in Kuala Lumpur
functioned as the headquarters of the NTP, and the state general hospitals with their chest
clinics functioned as the state directorates. At that time, the recommended treatment for TB
could last for 1-2 years.

Since 1995, the national TB directorate shifted to the Public Health Division of the Ministry
of Health and is now under the Director of Disease Control (Figure below). From the
operational point of view, every state has a state TB directorate which is known as the State
TB Managerial Team (Figure below). This team is responsible for the implementation of the
activities of the NTP at the state and district levels. The National TB Centre has now been
renamed as The Institute of Respiratory Medicine.

119
 Health Director

Deputy Director Deputy Director Deputy Director

(Health) (Management) (General health)

Hospital Director Disease control Director

Respiratory Institute Director Deputy Director of Communicable Disease

Department

Chief Assistant Director

Assistant Senior Health Assistant Administrative

Director Inspector Record

Figure showing the organization Chart of National TB Control Program in Ministry of Health Malaysia

The health director chairs the TB control committee at the national level and he is assisted by
3 deputy directors who supervise the health, management and public health divisions. The
deputy director of health oversees the hospital director who is in turn responsible for
overseeing the respiratory institute director. The deputy director of general health supervises
the disease control director who in turn oversees the activities of the Deputy Director of
communicable disease department. Deputy Director of communicable disease is assisted by a
chief assistant director in supervising the assistant director, senior health inspector and
assistant of administrative record section.

120
 Health Director

Deputy Deputy Director

Director (Public health)
(Medical)

Director of Director of Disease

Medical Practice Control

Director of Deputy Director Department

Hospital of Communicable Disease

Respiratory General Health

TB/Leprosy Unit
Institute Director Laboratory
Director
State Health
Director

Figure showing the organisation chart of TB Control Committee-State level

At the state level, the TB control committee is chaired by the state health director. The two
deputy directors who report to him are in charge of the medical and public health divisions
and in they in turn oversee the activities of the hospital director and the medical officers of
health in each district respectively.

State Health Director

Deputy Director (Medical) Deputy Director (Public Health)

Hospital Director Medical officer of health

Figure showing the organizational chart of TB control units at state level

121
TB Control Strategies

Among the strategies adopted by the Ministry of Health Malaysian to combat TB includes

 improving health educational activities to educate public concerning early signs of TB

 ensuring all health personnel are screened for TB
 mandatory screening for all HIV cases and for high risk cases in institutions like
prisons and drug rehabilitation centres and implementing mandatory health screening
of foreign workers who wish to apply for jobs in Malaysia (this is conducted by
FOMEMA)
 improving contact tracing activities to detect TB contacts and defaulters
 enhancing training activity for health personnel and volunteers in detection, diagnosis
and treatment of TB, and improve laboratory facilities and capabilities of microscopic
examination
 cooperating with non-governmental organizations, private medical practitioners and
private hospitals to eradicate TB and
 excluding TB patients who were treated at government hospitals from hospital
charges.

Responsibilities of the TB Unit at the District Level

The responsibility of the TB unit at the district level is to receive and record all TB
notifications. They investigate and interview patients based on the reports to explore the
causes of infection and to prevent the transmission of TB. The contacts of the patients are
identified and screened. Health education concerning TB infection is also shared. This
exercise requires home and workplace visits. Home visits are also carried out for defaulters.
The officers in the unit are responsible for preparing reports which contain the vital statistics
including incidence, figures, location maps and other important data regarding TB. A copy of
these reports which may be daily, weekly, monthly and annual report is sent to state health
office and headquarters in Putrajaya.

The responsibility of detection and TB control activities involves all registered medical
practitioners and non‐governmental agencies besides the personnel in the TB unit. It is the
requirement under the Infectious Disease Act (1988) that all confirmed TB cases must be

122
notified to the nearest district health office using the Tuberculosis Information System (TBIS)
within a week of diagnosis. All high risk cases with TB symptoms are also screened for TB.
The detection of symptomatic cases is usually done at the high risk wards in hospitals, and in
the ‘Klinik Kesihatan’ and the outpatient departments where 5% of outpatient attendees are
randomly selected. Patients with diabetes are also screened in the outpatient departments and
health clinics. Similarly all HIV patients and carriers are screened for TB and all TB patients
are screened for HIV. All the screening results are compiled in a report which is forwarded to
the state epidemiology officer. Screening for TB is also conducted in all institutions and
centres in which the inmates are at higher risk of TB e.g. drug rehabilitation centres, mental
institutions, old folk‘s homes and prisons, detention centres for illegal immigrants etc. It is
important to emphasize that all illegal immigrants tested positive are treated. The personnel in
the TB unit are responsible in the early detection of bacteriologically and/or radiologically
confirmed cases.

At the district level there are two centres namely ‘Pusat Rawatan Satu’ (PR1) (treatment
centre 1) and ‘Pusat Rawatan Dua’ (PR2) (treatment centre 2) which are involved in the
detection and management of TB cases. The following health centers are considered as ‘Pusat
Rawatan 1’ treatment centers

 government hospitals
 private hospitals
 Klinik Kesihatan with trained Family Medicine Specialist or Medical Officer
 respiratory clinics

The responsibilities of the staff in ‘Pusat Rawatan 1’ include to

 detect TB cases
 confirm diagnosis
 start treatment and case registration
 case notification
 patient follow up
 supervise ‘Pusat Rawatan 2’

123
The following centres are considered as ‘Pusat Rawatan 2’ treatment centres

 private clinics
 Klinik Kesihatan without trained Family Medicine Specialist or Medical Officer.
 Klinik Kesihatan without sufficient microscopic diagnostic tools
 Klinik Desa
 Klinik 1Malaysia

The responsibility of the staff at the ‘Pusat Rawatan 2’ include to

 detect cases using sputum test and refer patients to ‘Pusat Rawatan 1’ for further
management
 DOTS therapy
 refer complicated cases to ‘Pusat Rawatan 1’

High risk group for TB

People who have higher risk of contracting TB include:

a) Close TB contacts

b) Immunocompromised patients such as:-

• Diabetes mellitus
• Human Immunodeficiency Virus infection
• Chronic obstructive pulmonary disease
• End-stage renal disease
• Malignancy
• Malnutrition
• Use of immunosuppresant drugs in rheumatoid arthritis i.e. TNF blockers

c) Substance abusers and cigarette smokers

• Drug user (illicit drugs, intravenous drugs and hard drugs)
• Intravenous drug users
• Excessive alcohol consumption
• Current smoker

124
 d) People living in overcrowded conditions

• Homelessness
• History of incarceration
• Institutionalisation (such as homes for the elderly and shelters)
• Prison

Management of a newly diagnosed TB case in a health clinic

Figure below shows the flow chart for managing a newly diagnosed case with symptoms of
TB in a health clinic. Once a sputum positive case is notified to the district health office, the
Assistant Environment Health Officer is responsible to ensure that the contacts of the index
case (the primary case) are screened for TB. The index case is referred to the nearest health
clinic and a repeat sputum sample is taken after the second month of starting DOTS therapy
at a health clinic. If the repeat sputum sample is negative then the index case is allowed to
complete his treatment, however he/she is rechecked after every 3rd, 6th and 9th month. If the
repeat sputum sample is positive he/she will be referred to the chest clinic for further
management. In cases where the sputum sample of the index case is negative but the patient
is clinically symptomatic then he/she is referred to the chest clinic for further examination.
And if the chest clinic confirms the case as positive for TB, the index case is registered at the
nearest District health office and his contacts are examined.

125
 TB signs

AFB positive AFB negative

Refer to chest clinic

Case notification at the nearest DHO

Further examination
Confirmation and
examination of contacts
Confirmation of
TB case

Treatment started in the health clinic Case notification at the

with Family Medicine Specialist or nearest DHO

Sputum sample taken on 2nd month

Confirmation and
examination of contacts

Negative Positive

Follow-up Refer to chest

treatment clinic

Treatment
completed

Surveillance on
3rd, 6th and 9th
month

Flow chart for managing a patient first identified with TB symptoms

Tuberculosis Information System (TBIS)

Tuberculosis Information System (TBIS) is a system that was put in place of HMIS-TB
system which was previously used to collect, store, compile, transmit, analyse etc. for
planning purpose by the policy makers. Due to technical reasons, in 1999, a new system
called Tuberculosis Information System (TBIS) was created and fully launched in 2003.
TBIS is a system which uses paper forms to record information concerning TB from all the
clinics and healthcare centres from all over the country. It uses the same concept as the
Communicable Disease Control Information System (CDCIS) which is the nationwide
electronic online notification of infectious diseases.

The District Health Office forms as the headquarters for all data collection, management, and
gathering of reports including from all private healthcare facilities. Reports are compiled and

126
forwarded to the state health office at the end of every month. All information available
including laboratory results of individuals receiving treatment are available in the TBIS.

Case

Notification using TBIS1

Assistant Medical Record

Officer Only in Hospital

Medical officer of health

Verification of case by the CDC unit

District TB Organizer
team Ready with documentation e.g. contact tracing
etc.

Register District health officer confirms the case and register the case into TBIS

Chart for Case Detection and Notification at the district level

The figure above shows the process of notification of a new TB case at the district level. The
medical officer in a hospital is required to notify the CDC unit in the district health office of a
confirmed case. At the district health office the case is registered in TBIS and contact tracing
is immediately done. The case is followed up until he/she is completely cured using DOTS.

TB Treatment

The aim of TB treatment is to reduce morbidity, decrease transmission, prevent relapse and
the emergence of MDR-TB and ultimately prevent mortality. Tuberculosis is completely
treatable using an effective regimen of short-course chemotherapy but this requires the
patients to be compliant to their medications. According to the WHO it is estimated that 20
million lives are saved through the use of Directly Observed Treatment Short Course
(DOTS). Prior to DOTS, the attempt to reduce the global burden of TB failed miserably
because of the stigma, beliefs and superstitions associated with staying in a sanatorium.
Although new anti-tubercular drugs with daily regimen became popular worldwide, but TB
control programmes in most developing countries were still a failure mainly due to stigma

127
and lack of knowledge. Researchers in India, where TB was a major killer, formed the
strategy of placing the responsibility of curing the TB patient on the health workers rather
than the patients. They found that the effect of delivering the TB medication using this
Directly Observed Treatment was highly effective. The cure rates were so high that China
adopted it and similarly showed high cure rates and subsequently it is now use worldwide.

According to the WHO, the DOTS Strategy comprises of five elements

 Government commitment to a National Tuberculosis Control Programme

 Case detection of tuberculosis suspected cases through sputum smear microscopy
examination
 A standardized short-course tuberculosis treatment regimen of six months under direct
observation of a trained health care worker to ensure the patient takes every dose of
medication
 A regular, uninterrupted supply of quality anti-tuberculosis drugs
 A monitoring and reporting system to evaluate treatment outcome for each and every
patient with proper documentation

The objectives of the DOTS strategy is to successfully detect 70% of TB sputum-smear

positive cases in the population and to successfully achieve 85% recovery at the end of the
prescribed treatment for all new TB sputum-smear positive cases.

Difference between DOTS & DOT

DOTS is a strategy for TB Control Programme based on 5 elements explained above, while
DOT (Directly Observed Treatment) is one of the components of DOTS. Implementing
DOTS involves implementing all 5 components; on the other hand, DOT is an activity to
ascertain that a healthcare worker is assigned to monitor the patient taking the medicine i.e.
ensuring compliance to treatment.

128
Advantages of DOTS

DOTS has been proven to be economically sound. It has been reported to produce cure rates
of up to 95% even in the most economically challenged countries. Because of the low cost
involved in case detection using sputum microscopy and trained healthcare workers or
community volunteers to supervise the treatment, DOTS is easily integrated into the existing
primary health care services. Because of the DOTS strategy, the economic burden of
hospitalization and being absent from work coupled with isolation and stigmatization is
avoided. The patients remain with their families and if medically permitted, can return to
work in a few days. DOTS helps ensure compliance thus reducing drug resistance which is
much more expensive to treat and is often fatal. Another advantage of DOTS is that there is
proper recording and monitoring for each patient throughout the entire course of treatment
which leads to higher cure rates. In exceptional cases, patients are only hospitalized if they
are/have

 gravely ill
 inflicted with acute disseminated TB
 TB involving CNS, pericardium, and spine
 MDR-TB
 frequently defaulting treatment
 complications like haemoptysis, pneumothorax and empyema
 associated diseases such as uncontrolled diabetes or renal failure
 severe side effects like skin reactions and jaundice
 patients who need desensitisation to anti tubercular drugs.
 homeless, poor family support and other social indications

DOTS in Malaysia

In Malaysia, Directly Observed Therapy Short Course is the main strategy adopted to control
TB. Treatment is started as early as possible in a Respiratory Clinic or in the nearest ‘Klinik
Kesihatan’ by a registered medical practitioner. Stabilized patients can be followed up in any
nearest ‘Klinik Kesihatan’. TB treatment follows the standard Clinical Practice Guideline
issued by the Ministry of Health. The TB drugs are administered in the patients place of
residence or within the confines of a health care facility under the direct observation of health

129
personnel who records the event including the dosage. A repeat of sputum test after 2 months
of treatment to determine the sputum conversion is taken. This is part of the national level
quality indicator. Each state is required to analyse this indicator and forward the report to the
Disease Control Department. Relapse, retreatment and MDR-TB patients are placed under
the supervision of a respiratory specialist.

Treatment Regimens

Without treatment, a TB patient can infect up to 10 to 15 persons through close contact over
the course of a year and without treatment up to two thirds of people infected with TB will
die. Health education is an important component of TB management. The patient and his/her
family/caregiver are told of the nature of the disease, importance of compliance to treatment
and the risks associated with non-compliance, the side effects of medicine and the risk of
disease transmission.

According to the 3rd edition of the Malaysian Clinical Practice Guideline, TB treatment is
given in two phases i.e. Initial or intensive phase and continuation or maintenance phase.
During the intensive phase 3 to 4 drugs are given daily for a period of 2 months for rapid
sputum conversion followed by the maintenance phase where 2 to 3 drugs are given daily for
a period of 4 months. The maintenance phase may be extended for immune-compromised
patients.

Four drugs are considered as the first line treatment for TB. They are

 Isoniazid (H) 5 mg/kg max 300 mg (if isoniazid is prescribed, Pyridoxine* 10 - 50 mg

daily is added)
 Rifampicin (R) 10mg/kg max 600mg
 Pyrazinamide (Z) 25 mg/kg max 2000 mg and
 Ethambutol (E)15mg/kg max 1600 mg.
 Streptomycin (S) 15mg/kg max 1000mg**

*Pyridoxine (25mg daily) should be given to all pregnant women on isoniazid to

prevent foetal neurotoxicity
** Streptomycin is avoided in pregnancy due to foetal ototoxicity.

130
Drug Resistant TB

MDR-TB is defined as Mycobacterium tuberculosis infection resistant to both isoniazid and

rifampicin with or without resistance to other drugs. It is estimated that there are up to
450,000 million cases of MDR-TB and more than 170,000 deaths attributed to MDR-TB.
WHO surveillance suggests that 3.6% of newly diagnosed TB cases and 20% of previously
treated TB cases have MDR-TB. According to a 2011 report, 1.3% of all cultures performed
in Malaysia were confirmed to be MDR-TB.

The current recommended MDR-TB standard treatment is for 18 to 24 months. However it

yielded low cure rate as patients are unable to keep taking the medicines, they often interrupt
the treatment and lost to follow-up. As of 12 May 2016, WHO has recommended a shorter
MDR-TB regimen. The shorter regimen is recommended for patients with uncomplicated
MDR-TB (for those not resistant to fluoroquinolones and injectables) and for those patients
who have not yet been treated with second line drugs.

The features of shorter MDR-TB regimens include:

 Standardized shorter MDR-TB regimen for a duration of 9 to 12 months, with 7 drugs

 Indicated for MDR-TB or rifampicin-resistant-TB (regardless of age and HIV status)

However, the shorter MDR-TB regimens should not be given to patients who are resistance
with 2nd line drug resistance, who has extrapulmonary disease and who is pregnant.

The regimen composed of:

4 - 6 Km – Mfx – Pto – Cfz – Z –Hhigh – dose - E / 5 Mfx-Cfz-Z-E

Km=Kanamycin; Mfx=Moxiflox acin; Pto=Prothionamide; Cfz=Clofazimine;

Z=Pyrazinamide; Hhigh-dose= high-dose Isoniazid; E=Ethambutol

131
Also in May 2016, WHO recommended to use rapid diagnostic test – a line probe assay to
detect resistance to second-line anti-TB drugs (SL-LPA). This test is for identifying those
MDR- or rifampicin-resistant TB patients who can be placed on the shorter MDR-TB
regimen.

This is the only WHO-recommended rapid test for detection of additional resistance in MDR-
TB patients as well as XDR-TB. It is the most reliable way to rule out resistance to second-
line drugs.

The SL-LPA produces results in just 24-48 hours, It allows quick triage of confirmed
rifampicin-resistant or MDR-TB patients into either the shorter MDR-TB regimen or the
conventional longer regimen. Detection of any second-line resistance by the SL-LPA means
that MDR-TB patients should not be enrolled on the shorter regimen.

132
Figure showing the percentage of new TB cases with MDR-TB. Taken with from WHO global tuberculosis
report 2012

Extensively drug resistant tuberculosis (XDR-TB) is a condition when the mycobacterium

tuberculosis infection is resistant to isoniazid and rifampicin plus resistant to any
fluoroquinolones and at least one of three injectable second-line aminoglycosides
(capreomycin, kanamycin, and amikacin). The diagnosis of both are confirmed by culture and
sensitivity test of relevant specimen. Extensively drug resistant TB, has been reported in 92
countries and this list is expanding becoming a major public health problem. The average
proportion of MDR-TB cases with XDR-TB is 9.6%.

133
Figure showing countries that had notified at least one case of XDR-TB by the end of 2011. Taken from WHO
global tuberculosis report 2012

Management of resistant TB

The second line drugs used for MDR-TB comprises of

 Amikacin -15mg/kg/day 5x week,

 Ofloxacin 400-600mg/day
 Ciprofloxacin-750-1500mg/day
 Cycloserine-15/mg/kg/day
 Clarithromycin-500mg bd
 Azithromycin-500mg od
 Paraamino salicyclic acid-12-16gm/day
 Ethionamide-15-20mg/kg/day and
 Clofazamine-100-300mg/day

MDR-TB is not managed in Klinik Kesihatan and requires treatment in respiratory clinic
under close supervision of a chest physician.

134
Case definitions relating to TB

New case – is a patient who has never been treated for tuberculosis or has taken anti-
tuberculosis drugs for less than 4 weeks duration in the past. New case can be sputum
positive or sputum negative:

a) New smear positive PTB: A patient who has never received treatment for TB, or who
has taken anti-TB drugs for less than 30 days and who has
one of the following:
 two or more initial sputum smear examinations positive for AFB;
 one sputum examination positive for AFB plus radiographic
abnormalities consistent with active PTB as determined by a clinician; or
 one sputum specimen positive for AFB and at least one sputum specimen that
is culture-positive for AFB
b) New smear negative PTB: A case of PTB that does not meet the above definition for
smear-positive TB, which is diagnosed clinically or radiologically by clinician.

Relapse case - there are several types of relapse cases which include

Sputum positive relapse- a patient who has undergone one full course of
chemotherapy and has been declared cured of any form of tuberculosis in the past by
a doctor, and has become sputum smear positive.

Sputum negative relapse- a patient who has undergone one full course of
chemotherapy and was declared cured of any form of tuberculosis in the past by a
doctor but has developed active disease based on bacteriological (culture),
histological or clinical and radiological assessment

Chronic case - A patient who remained or becomes smear positive again after completing a
fully supervised re-treatment regimen

Treatment failure - a patient who, while on treatment, remained or becomes again, smear
positive 5 months or later after commencing treatment. A patient who is smear negative
before starting treatment and became smear positive after the second month of treatment is
also considered as treatment failure.

Transferred in case - a patient transferred from another centre for continuation of the
treatment of tuberculosis. A transfer implies that the centre to which the patient is transferred

135
undertakes the responsibility of continuing to treat the patient and supervising progress. A
patient is not considered to have been transferred if he/she presents at another treatment
centre merely to obtain treatment.

Abandoned treatment - is when a patient who defaults treatment for a month or more.

Missed treatment - is when a patient misses one dose of treatment as scheduled

Latent TB- is a patient who has been infected but has no clinical manifestation of the disease
actively. The mycobacterium tuberculosis may be alive but it is in a state of dormancy and is
not causing an active disease/symptoms. It is estimated that almost one third of the world’s
population has latent TB.

Defaulter - a patient who has interrupted treatment for two consecutive months or more.

Defaulter tracing

Treatment centres are required to inform the District Health Office concerning patients who
default treatment for 1 week. It is important that defaulters are identified immediately and the
responsibility of tracing the defaulters fall on the Assistant Environmental Health Officer
(AEHO) of the district.

There are 3 types of defaulters:

Treatment defaulters- the most important of whom are sputum positive patients who are on
treatment and who fail to attend the supervised daily or biweekly chemotherapy or fail to
collect their supply of drugs for self-administered oral chemotherapy

Review defaulters - patients who fail to attend follow up appointment for review of sputum,
other examinations, progress review and further management after the completion of
examination.

Patients who default review while undergoing investigations- to rule out active tuberculosis.

Figure below shows the process of defaulter tracing in TB Cases. When a patient fails to take
the DOT therapy even for a day the defaulter is immediately traced by calling the patient. If
the patient is not contactable or is persistently absent, a house visit is made by the nurse and
if still not contactable then the AEHO in charge of TB cases at the District health officer is

136
alerted. The AEHO then traces the defaulter for a period of 2 months following which the
patient is recorded as a missing case. If however the patient is found he/she is firmly told to
resume the DOTS treatment until completion.

Patient absent

Call the patient

Yes
Are you able to contact the patient?

No

Nurse/Medical Assistant comes for home

visit next day

Yes
Order the patient to go to
Give treatment by Found the patient?
treatment center
DOTS

No

Refer to AEHO on day 3 with form TBIS 10D

Yes

Found the patient?

No

Trace the patient for every

week up to 2 months

Missing/End

Figure showing the process of TB defaulter tracing employed by the Ministry of Health

137
Contact tracing

Because TB is a notifiable Disease, all confirmed TB cases (bacteriology &/or radiology &/or
clinical) are notified to the nearest District Health Office within 1 week of diagnosis. This
helps in the process of tracing the contact. A contact is someone who is living together or is
always in contact with the TB patient. The risk of infection is dependent on the degree of
shared ventilation, physical distance and duration of exposure. Priority of contact tracing is
given to contact of sputum positive cases and contacts in the high-risk groups and children up
to 14 years old. Contact tracing is conducted immediately upon receipt of information from
treatment centres. Upon registration, the index case is required to inform the AEHO
regarding his/her contacts who are then called to the clinic (the nearest Pusat Rawatan 1) for
investigation. When a child is diagnosed to have tuberculosis, all the members of the family
are investigated. Household contacts who give a history of coughing of more than two weeks
duration and children found to have no BCG scar during home visits are required to visit the
nearest health facility for further investigations.

TB Contact

Chest X- ray

Abnormal Normal

Asymptomatic Symptomatic

Repeat test 3rd, 6th and 12th Refer to Respiratory clinic

month

Further examination

Sputum positive Sputum negative

Asymptomatic Symptomatic
New patient

Repeat test on 6th

and 12th month

Figure showing the examination of an adult in contact with TB

138
Figure above shows the steps involved in contact tracing of an adult patient at the district
level. If chest x-ray is abnormal but the contact is clinically asymptomatic the contact is
advised to repeat the test 3rd month after the first test and again if necessary 6 months after the
second test and again 12 months after the third test if necessary. If chest x-ray is abnormal
and the patient is clinically symptomatic, he/she is referred to the chest clinic where the
contact’s TB status is confirmed using sputum test. If the result is positive he is registered as
a new TB case but if the sputum result is negative the test is repeated after 6 th and 12th month
after the first test.

However, according to the Malaysian CPG on TB the recommended contact tracing steps for
adults is depicted in the diagram above.

139
Figure above shows the flowchart for the management of a child contact with TB. Child who
had contact with a TB patient, will be subjected to undergo a Mantoux test. If the immune
reaction shows a reading of <10mm, the child will be inquired whether he/she has any
symptoms. If the child is asymptomatic, the child is checked for a BCG scar. If no scar is
noticed then the child is advised to undergo BCG vaccination but if the asymptomatic child
has a scar then the child is advised for further follow up. If the child is symptomatic then
he/she is referred to do a chest X-ray and if found abnormal the child is referred to a chest
clinic for further treatment. If the child’s Mantoux test shows an immune reaction of more
than 10mm, a chest X-ray is done and if it is normal and the child has symptoms suggestive
of TB, the child will be treated as TB patient. If the chest x-ray is abnormal, the child will be
treated at TB patient as well. If the chest x-ray is normal and the child is asymptomatic, and if
the child is below 5 years he/she will be treated as LTBI. However, if the child is more than 5
years, he/she will be advised to do a follow-up.

140
Picture TB1 and 2. Huge TST response (25cm at largest diameter; 20cm at shortest diameter; shortest is used as
standard measurement. Courtesy Prof Richard (PMC).

Challenges in the fight against TB

Due to ignorance, there is an increase in defaulters and decrease in compliance to treatment

which is forming a major threat to this programme. Most patients with TB seek treatment due
to the symptoms, these symptoms resolve within the first few weeks of treatment, because of
this patients lose their commitment to complete the full drug regimen. Stigma is another
challenge to the success of the programme. Stigma to TB, like to many other illnesses, is
associated lack of knowledge concerning the disease. Stigma may cause infected person to
not seek treatment and patient on treatment to default treatment. Malaysia has a rapidly
developing economy resulting in the influx of foreign workers to meet the demands of work
force which cannot be met by the local population. Most of these foreign workers originate
from countries which have high prevalence of TB. Although all efforts are made to screen the
workers for TB and other infectious diseases but there are substantial illegal immigrants who
are working in the country and who may be infected with TB.

Internationally the fight for TB is threatened by the lack of commitments by governments

especially on funding because many countries which are affected by this epidemic are
economically challenged. Poor reporting mechanism and lack of local research compounds
the problem. Insufficient new and fast diagnostic tools and newer drugs and the use of
unregulated TB treatment regimens especially in the private sector is a challenge for the
WHO in its fight for TB.

It is important to remember there are many enabling and reinforcing factors in TB like
malnutrition, diabetes, alcohol use, smoking and air pollution that also need to be addressed
along with other TB control measures.

141
 B. HIV/AIDS
Human Immunodeficiency Virus (HIV) which is transmitted though body fluids from an
infected person, targets the immune system by destroying the immune cells. People with
HIV infection are susceptible to infections like pneumocystis carinii pneumonia and certain
cancers like Kaposi’s sarcoma. Acquired Immunodeficiency Syndrome (AIDS) which is the
most advance stage of HIV infection and can take up to 2 and 15 years to develop.

It is commonly believed that the virus is a mutation of the Simian immunodeficiency virus
which is found in non-human primates, however the actual method of the transmission from
the monkeys to humans in still unclear. Although it is generally believed that the disease has
been around for some time but it was only in 1981 did it receive much publicity. At one time
the syndrome was called the Gay Related Immune Deficiency because it was first recognised
among homosexual men in the United States. Only in 1983 was the etiological agent HIV
was identified by Dr Robert Gallo in the United States. Although HIV infection was
predominantly detected among men who had sex with other men and among the injecting
drug abusers but now the infection is also common through heterosexual contacts. Although
almost all countries in the world have reported the incidence of HIV infection but the the
prevalence of HIV and rates of infection is highest in Africa. South Africa has reported the
largest number of people living with HIV/AIDS in the world.

Since the beginning of the epidemic, more than 60 million people have been infected with the
HIV virus and approximately 30 million people have died of AIDS. According to the WHO
there were around 35 million people were living with HIV worldwide in 2012. Most of the
reported infections occurred in the sub-Saharan region where nearly 1 in 20 adults were
living with HIV accounting for 69% of all people living with HIV. According to Joint United
Nations Programme on HIV and AIDS (UNAIDS) the number of people living with HIV in
in the Pacific region almost doubled between 2001 and 2009 from 28,000 to 57,000.
However the is a decreasing trend in new infections. According to the UNAIDS report, the
number of new HIV infections reported globally in 2012 reduced to 2.3 million compared to
3.4 million new cases reported globally in 2001, this accounts for a 33% decline. Deaths due
to AIDS have also declined to 1.6 million in 2012 from 2.3 million reported in 2005. This is
due to the expanded and improved HIV programmes and the increase in the access to
antiretroviral therapy especially in low and middle income countries. It is reported that more
than 9.7 million people living with HIV were receiving antiretroviral therapy (ART). 53% of

142
pregnant women living with HIV had access to antiretroviral medicines to prevent
transmission of HIV to their infants*. Deaths rates related to HIV/AIDS and prevention of
infections from infected mother to child can further be reduced by expanding the use of ART.
At present patients receiving ART only accounts for 35% of the estimated need.

In the South and South East Asia the epidemic started in the mid to late 80’s and the countries
reporting the most infections were Thailand, India, Cambodia and Myanmar. The HIV
epidemic in this region is mainly driven by high-risk behaviours, including unprotected
commercial sex, unprotected sex between men and unsafe injecting drug use (IDU). Papua
New Guinea has a generalized epidemic while Cambodia, China, Malaysia and Vietnam have
concentrated HIV epidemic in people with high-risk behaviours. The epidemics in these five
countries make up the bulk of HIV burden in the region. According to a UN report, Malaysia
is one of the countries which have reported increasing HIV prevalence among IDU’s.

*HIV transmission from an HIV positive mother to her child during pregnancy, labour, delivery or
breastfeeding is called vertical or mother to child transmission.

HIV/AIDS in Relation to Millennium Development Goals

MDG 6 deals with HIV/AIDS, it calls for actions to halt and begin to reverse the AIDS
epidemic. According to the UNAIDS report 2013 the indicators set are

 Reduce sexual transmission of HIV by 50% by 2015- according to this report although
the number of new HIV infections has reduced among adolescents and adults by 50%
but not all countries have been able to achieve this so far.
 Halve the transmission of HIV among people who inject drugs by 2015- according to
the report, this is not on track. Prevalence of HIV among IDU’s is 28% in Asia.
 Eliminate HIV infections among children and reduce maternal deaths- according to
this report, antiretroviral coverage among pregnant women living with HIV reached
62% in 2012 and the number of children newly infected with HIV in 2012 has
reduced.
 Reach 15 million people living with HIV with lifesaving antiretroviral treatment by
2015- the provision of antiretroviral therapy helps prevent AIDS related illness and
death and significantly reduces risk of HIV transmission.

143
 Halve tuberculosis deaths among people living with HIV by 2015-tuberculosis related
deaths among people living with HIV have been steadily declining with active
treatment
 Close the global AIDS resource gap- mobilization of financial resources is a
challenge as most developing countries which still depend on international assistance
 Eliminate gender inequalities and gender based abuse and violence and increase the
capacity of women and girls to protect themselves from HIV – according to the
UNAIDS report women who experience intimate partner violence are 50% more
likely to be living with HIV.
 Eliminate HIV related stigma, discrimination, punitive laws and practices- a
substantial number of countries have regulations and policies that prevent obstacles to
HIV prevention and treatment of vulnerable people. Although there are no reported
cases of denied health or dental services or denied family planning services in
Malaysia, it is reported that 12% of people living with HIV have reported refusal of
employment between 2008 and 2013.
 Eliminate HIV related restrictions on entry, stay and residence- such restrictions are
discriminatory towards people living with HIV and promote stigma. Malaysia is one
of the countries reported by the UN to have such restrictions but is on track to lifting
such restrictions by 2015.
 Strengthen HIV integration – integration of HIV with other services is to reduce
duplication of services. According to the UNAIDS report 2013 there are many health
services in Malaysia that provide HIV services integrated with other health services
which include; ART and chronic non-communicable diseases, ART and general
outpatient care, ART and tuberculosis, HIV counselling and testing and chronic non
communicable diseases, HIV counselling and testing and general outpatient care, HIV
counselling and testing and tuberculosis, HIV counselling and testing with sexual and
reproductive health.

144
The WHO global health sector strategy on HIV/AIDS 2011 to 2015 guide to health sectors
response to HIV was developed to promote long term, sustainable HIV response by
strengthening health and community systems and addressing the social determinants and
protecting and promoting human rights. It has four main strategies with its own core elements
which include

 Optimize HIV prevention, diagnosis, treatment and care outcomes

 Revolutionize HIV prevention
 Eliminate HIV infection in children
 Catalyse the next phase of treatment, care and support
 Provide comprehensive and integrated services for key populations

 Leverage broader health outcomes though HIV responses

 Strengthen links between HIV programmes and other health programmes

 Build strong and sustainable systems

 Strengthen the six building blocks of health systems

 Reduce vulnerability and remove structural barriers to accessing services

 Promote gender equality and remove harmful gender norms
 Advance human rights and promote health equity
 Ensure health in all policies, laws and regulation’s

145
Malaysia in Relation to HIV

Epidemiology of HIV/AIDS in Malaysia

Reports on the number of new cases, deaths etc. vary according to different reports.
According to the estimate and projection report of the Ministry of Health Malaysia, the
number of people living with HIV (PLHIV) up to 2011 was estimated at 81,000. And
according to the annual report of MOHM relating to HIV/STI, by the end of 2011, Malaysia
had a cumulative figure of 94,841 HIV, 17,686 AIDS and 14,986 deaths, thus giving reported
PLHIV of 79,852. HIV is reported to be higher in the male population and in the high risk
populations especially injecting drug users, sex workers and trans genders. Just like in most
countries injecting drug use was the main source of transmission followed by sexual
transmission but in 2011 sexual transmission has overtaken injecting drug use as the main
source of transmission. A quarter of reported cases are among the 13 to 29 age group.

UNAIDS Report 2013 Relating To Malaysia

According to the estimates of the UNAIDS report 2013 concerning Malaysia, it was
estimated that the prevalence of HIV among adults aged 15 to 49 was 0.4 in 2012 compared
to the global prevalence of 0.8. In the same report it was estimated that 82,000 people were
living with HIV compared to the global estimate of 35,300,000. 81,000 of the PLHIV were
aged 15 and above compare to the global estimate of 32,100,000. In 2012 there were 7,400
new infections in Malaysia compared with 2,300,000 globally, 7,300 of these infections were
people aged 15 years and above compared to 2,000,000 globally in the same age group. There
were 12,000 HIV infected female adults in 2012. The percentage of female young people
aged 15 to 24 living with HIV in 2012 in Malaysia was <0.1% and male 0.1%. AIDS related
deaths reported were 5,200 in 2012 compared to 1,600,000 reported globally.

In the same report it was estimated that in 2010 there were 60,000 sex workers in Malaysia
and 10% of the sex workers were living with HIV. In 2012, 61% of the sex workers in
Malaysia reported using condom with the most recent client. It is estimated that 12.6% of
men who have sex with men are living with HIV in 2012. 77% of men reported using
condom when they last had anal sex with a male partner in 2012 compared with only 21% in
2009.

146
It is estimated that 19% of the estimated HIV positive incident TB cases received treatment
for both TB and HIV in 2012. 434 HIV positive tuberculosis patients were on antiretroviral
therapy in 2012.

Reported HIV cases and notification rate 2000-2008

8000 30

7000
25
6000
20
5000
Axis Title

4000 15

3000
10
2000
5
1000

0 0
2000 2001 2002 2003 2004 2005 2006 2007 2008
No Screened 5107 5938 6978 6756 6427 6120 5830 4549 3692
Notification rate 22 25 28 27 25 23 22 17 13.3

HIV/AIDS Prevention Strategies

When AIDS and death related to HIV/AIDS was included into the list of notifiable diseases
in the year 1985, under the Prevention and Control of Infectious Diseases Act, it was one of
the initial steps taken to combat HIV in Malaysia. The National HIV/AIDS Task Force,
which was an inter-sectoral committee chaired by the Director General of Health, was formed
in 1985. The national task force was responsible for formulating policies and strategic plans
as well as to coordinate the HIV/AIDS prevention programme in the country. Following this
a State Coordinating Committee on AIDS was established in every state and it was given
responsible for implementing and coordinating AIDS prevention and control activities in
each state. The government also formed an Inter-Ministerial Committee, chaired by the
Minister of Health and assisted by the National HIV/AIDS Technical and Coordinating
Committee which had replaced the functions of the National HIV/AIDS Task force. This new
committee was responsible for advising the cabinet on all matters pertaining to the
prevention, control and management of HIV/AIDS in Malaysia. In the year 1993, an
AIDS/STD subdivision was created under the Disease control Division which serves as the
Secretariat to the Ministerial, Technical and Coordinating Committees on HIV/AIDS. The

147
AIDS/STI Section has three units, prevention and health promotion, surveillance, and care.
This section is responsible for planning, organising, implementing, monitoring, evaluating
HIV/AIDS prevention and control programmes, activities carried out by NGO’s as well as
training and research activities. This HIV/STI section functions as the national AIDS
programme secretariat and is supported by the AIDS officers in each state.

The general objectives at the national level are to

 prevent HIV/AIDS transmission and to control its spread
 reduce the morbidity and suffering associated with the infection
 reduce the impact on the individual, family, community and the nation
 mobilize resources available for the control of HIV/AIDS and
 promote collaboration and teamwork of the various agencies at local, national and
international levels

The national strategic plan on HIV/AIDS has five main strategies which include
1. improving the quality and coverage of HIV/AIDS prevention programmes among the
most at risk and vulnerable populations
2. Improving the quality and coverage of HIV testing and treatment
3. Increasing the access and availability of care and support for people living with HIV
and those affected
4. Maintaining and improving an enabling a positive environment for HIV prevention,
treatment, care and support
5. Increasing the availability and quality of strategic information and its use by policy
makers and programme planners through monitoring, evaluation and research.

At the district level the strategies employed by the unit are

 the provision of information, education and communication in relation to HIV/AIDS
 the promotion of healthy lifestyle practices
 early detection of HIV infection cases
 the provision of appropriate medical/health services and supportive care at institutions
and at community levels
 harm reduction for the vulnerable and at risk groups and
 monitoring HIV situation through surveillance and epidemiological measures.

148
List of duties of personnel in HIV/AIDS unit at the district level
The duties of the personnel in the unit include to
 plan, implement and monitor programmes at district level
 identify problems and provide feedback on the prevention of HIV programme at
district level
 collect and register cases from health clinics in the districts
 plan and implement prevention of HIV programme activities at district level
 provide feedback on the implementation of programme to the state office
 receive all notifiable cases and search for contacts of the HIV patients.

The National Strategic Plan on HIV and AIDS

The National Strategic Plan (NSP) on HV and AIDS 2011-2015 was developed in accordance
to the objectives of the 10th Malaysia Plan. The first NSP was formulated in 1998
subsequently 2006-2010 before the present one. The present NSP has three components
 The national strategic plan on HIV and AIDS 2011-2015
 The national plan of action on HIV and AIDs 2011-2015
 The national monitoring and evaluation framework

The goals of the NSP are to

 prevent and reduce the risk and spread of HIV infection
 improve the quality of life of people living with HIV and
 reduce the social and economic impact resulting from HIV and AIDS on the
individual, family and society

The specific objectives include to

 further reduce by 50% the number of new HIV infections by scaling up, improving
upon and initiating new and current evidence based comprehensive prevention
interventions
 increase coverage and quality of care, treatment and support for people living with
HIV
 alleviate the socioeconomic and human impact of AIDS on individuals, family,
community and society

149
  further increase general awareness and knowledge of HIV and reduce risk behaviours
for at risk and vulnerable populations

In order to achieve these objectives the following strategies are outlined in the NSP
 Improving the quality and coverage of prevention programmes among the most at risk
and vulnerable populations
 Improving the quality and coverage of testing and treatment
 Increasing the access and availability of care, support, and social impact mitigation
programmes for people living with HIV and those affected
 Maintaining and improving an enabling environment for HIV prevention, treatment,
care and support
 Increasing the availability and quality of strategic information and its use by policy
maker and programme planners through monitoring, evaluation and research

Training of medical, health and other related staff

Because continuous manpower training is essential for the effective implementation of the
National HIV/AIDS Prevention and Control Programme, in service training activities
especially relating to universal precaution and counselling and updates on HIV/AIDS are
planned and implemented to cater for the needs and functions of the staff. Health care
providers working in corrective institutions such as prisons, and rehabilitation centre are also
trained in HIV/AIDS counselling. The HIV/AIDS related topics are also incorporated into the
teaching curriculum of medical schools and other allied health professions training courses.

Inter-agency and inter-sectoral collaboration

Considering that there are many players involved in the prevention and control of HIV/AIDS
programme in the country, inter-agency and inter-sectoral collaboration is essential to
enhance the effectiveness of the HIV/AIDS prevention activities. An organized and an
established concerted and coordinated response from the different agencies including
government and NGO which has its own strengths and weaknesses, as well as experience and
expertise help complement and synergistically enhance the efficiency and effectiveness of the
prevention programmes. The collaboration and linkages between the various sectors and
organizations in HIV/AIDS prevention, education and care is planned at all levels including

150
national, state, district and community for the successful implementation of the programme.
Among the non-Health sectors include the Ministry of Women, family and community
development, national anti-drug agency, Jabatan Kemajuan Orang Asli (department of
indigenous people), Islamic departments, Prisons department, information ministry etc.

Exchange of information, experience and expertise

Free flow of information and exchange of experience and expertise to enrich the response to
HIV/AIDS management among the players involved in the HIV/AIDS programme is
practised.

International co-operation and collaboration

Because HIV/AIDS is a pandemic, international cooperation and collaboration is of utmost

importance. Networking is established in the field of research and exchange of information
and experiences in the prevention and control of the HIV/AIDS is done through global health
diplomacy. Various international bodies such as UNAIDS, WHO and ASEAN especially the
ASEAN Task Force on AIDS are important partners in the various HIV/AIDS prevention and
cross border programmes which are jointly developed.

Research and evaluation

Due to the dynamic change in the epidemiological and behavioural patterns relating to risk
factors for HIV/AIDS requires stringent monitoring. Hence the Ministry of Health is heavily
invested in the interventional research and critical evaluation of existing programmes and is
proactively developing and adapting effective prevention and control strategies.

Capacity building

United Nations Development Programme (UNDP) defines capacity building as a long time
development that involves all stakeholders using the available capabilities to tackle problems
related to policy and methods of development while considering the potential limits and
needs of the people. Various sectors including health care providers, non-health agencies,
private sectors and non-governmental organizations are involved in the response to the
HIV/AIDS epidemic. Because these organizations participate, take ownership, and are pro-
active by investing in capacity building, they are provided with updated information for better
understanding matters concerning HIV infection and AIDS and related issues. Capital
building programmes are identified and are implemented continuously at all levels. They may

151
be in the form of workshops, seminars, dialogue etc. and they cover all categories of staff.
The recourse required which may include financial and/or manpower are made available to
facilitate and enhance the capability building efforts.

Care and support

Stigma which is attached to HIV infection and AIDS has led to the discrimination and
prejudice towards not only those infected but also the families of those infected. Because of
stigma, people are shunning away from testing voluntarily. Those diagnosed with HIV are
reluctant to inform family members and friends for fear of rejection. Because of the
misconception mostly due to the lack of adequate and correct information concerning
HIV/AIDS especially its transmission, has led some families and care givers to provide
inadequate care and support. To fight this, the ministry of health, provides a continuous
health education and disseminate information to the community in order for them to be better
informed and subsequently assist in the desensitization of the HIV infection. To create a
supportive environment for people living with HIV, the Ministry of Health promotes greater
participation of the various sectors and agencies, together with the family members, friends
and local communities in the prevention programmes.

Strengthening Leadership and Advocacy

As with all disease control efforts, the role and involvement of leadership is crucial.
Leadership, at national, state and community level, is responsible to mobilize and co-ordinate
actions across sectors and to direct resources and activities to the most urgent priorities.
Strong leadership creates an environment where government partners and Non-governmental
organizations (NGO) can participate in the response. Stigma and discrimination which inhibit
open communication concerning HIV/AIDS issues and the active involvement of
community-based groups can be overcome leading to an equitable access to treatment, care
and other support services.

According to a toolkit for public health professionals published by the public health advocacy
institute of Western Australia, advocacy in public health is similar to advocacy in social
justice; “the pursuit of influencing outcomes, including public policy and resource allocation
decisions within political, economic and social systems and institutions that directly affect
people’s lives”. Advocacy at the highest level involves the strategies planned for the
prevention and control of HIV/AIDS in aspects of the government plan for development and

152
international collaborations e.g. the Association of South East Asian Nations (ASEAN) and
United Nations. These international collaborations especially with the UN help the
government access to international expertise in the field of advocacy, technical and provide
access to international institutions.

Training and Capacity Enhancement

In order to increase the quality of the response to HIV/AIDS by increasing the coverage and
quality of prevention, care and support services as well as the use of HIV surveillance data to
shape policies and programmes, the capacity of the health system and non-government
organizations (NGO) is intensified.

Funding
According to the UNAIDS Report 2013, in 2012 Malaysia spent a total of USD 56,142,280
from domestic and international sources. USD 54,416,987 domestic HIV spending was from
domestic public sources and USD 1,725,292 from global fund. However there is a worry that
this method of funding may not be sustainable in the long run.

Antiretroviral treatment, resource mobilization and funding support

For the NSP 2011-2015 the government has made a commitment to provide first line ART
treatment at no cost for patients who need it including inmates in prisons and drug
rehabilitation centres. It is reported that 14,594 adults of the estimated 45,000 adults in 2012
who needed antiretroviral therapy based on the 2010 guidelines were on antiretroviral
therapy. A total of 490 children aged 0-14 years were receiving ART. It is projected that
60,000 people are in need of antiretroviral therapy according to the 2013 WHO antiretroviral
criteria guidelines.

Harm reduction programme

It was estimated that 18.9% of people who inject drugs are living with HIV in 2012. With the
collaboration of the Non-Governmental Organizations and other community based
organizations and private practitioners, the MOH has implemented the needle syringe
exchange programme and the methadone maintenance therapy. It is reported that more than
40,000 IDU have successfully benefited from this programme. The percentage of people who

153
inject drugs who reported using sterile injecting equipment the last time they injected was
98% in 2012. The number of syringe distributed per person who injects drugs per year by
needle and syringe programmes in Malaysian in 2012 was 94, although Malaysia is reported
to have a high syringe distribution among middle income countries but it is much lower than
most high income countries. The percentage of people who inject drugs who reported the use
of a condom at last sexual intercourse was 27% in 2012. The coverage on opiate substitution
therapy in Malaysia was reported at 26%.

Prevention of mother to child transmission

This programme was started in 1998 and is based on the provision of ART prophylaxis. All
expecting mothers receiving antenatal care in government facilities are screened. It is
estimated that 100% of infants born to HIV positive women received a virological test for
HIV within 2 months of birth. It is reported that 342 pregnant women living with HIV
received antiretroviral therapy to preventing mother to child transmission.

Public Health Approach in HIV/AIDS Prevention

After more than 30 years since HIV/AIDS became a pandemic and despite the money and
time spent on looking for a cure there is still no cure or vaccine available. Prevention is still
the main and only available effective strategy in dealing with the HIV/AIDS pandemic.
Public health approach is extremely important in dealing with HIV/AIDS. The three levels of
prevention is the key for the effective prevention and control of HIV infection. Health
education, health promotion and information dissemination concerning HIV/AIDS as the
primary prevention strategy has successfully reduced high risk activities and has contributed
to better understanding of the illnesses and subsequently reduced stigma. Early diagnosis
through HIV screening programme has been shown to be effective in not only increasing the
life expectancy of the victims by early treatment but also reduced further transmission of the
disease.

Routine screening, for example of pregnant women, is an important tool in determining HIV
prevalence in Malaysia.

154
HIV surveillance system in Malaysia

Systematic HIV/AIDS surveillance started in Malaysia in 1987 and was further strengthened
in 1998 with the introduction of Plan of Action for Prevention and Control of HIV in
Malaysia and the introduction of Prevention and Control of Infectious Diseases Act, 1998
(Act 342). The National AIDS Task Force under the supervision of the Ministry of Health
drafted the National Strategic Plan in 1998 which formed the basis of the Plan of Action in
which the HIV/AIDS surveillance system is outlined for Prevention and Control of
HIV/AIDS.

The four main objectives of HIV/AIDS surveillance in Malaysia is to

 identify the trends of HIV infection and AIDS in the country

 identify the incidence and prevalence of HIV infection and AIDS
 identify the risk factors associated with HIV infection and AIDS
 assist the Ministry of Health in evaluating and monitoring the Prevention and Control
Programmes for HIV/AIDS

155
Types of HIV Surveillance System in Malaysia

Surveillance which is the on-going systematic collection, analysis and interpretation of

infectious disease data is essential for planning, implementation and evaluation of health
activities. It is closely integrated with the timely dissemination of information derived from
these data to relevant persons/authorities, so as to take appropriate action. In other words
information for action!

There are three types of HIV surveillance system in the country

Active surveillance – active surveillance is the purposeful gathering of information from

institutions and health care providers or populations by the health department. Although it is
very accurate it is also very expensive. Examples of this type of surveillance are the
anonymous HIV voluntary screening programme, voluntary HIV screening of expecting
mothers at government antenatal clinics, HIV screening at Drug Rehabilitation
Centres/Prisons, HIV screening of confirmed Tuberculosis cases and patients with suspected
clinical symptoms, traced contacts of confirmed person with HIV, mandatory confidential
HIV screening of donated blood and mandatory confidential HIV screening of foreign
workers

Passive – this is the type of screening in which the health department routinely receives
reports submitted from hospitals, clinics, etc. Although it is relatively less expensive
compared to active surveillance and it covers larger areas but the quality of data may not be
as reliable. It is mandatory to notify all HIV/AIDS cases under the Act 342 (explained further
under ‘Notification’ below), hence all HIV infections and AIDS cases diagnosed by
registered medical practitioners are required by Law to report to the health department.

Sentinel –it means keeping watch of HIV/AIDS. Findings of a sentinel data collection are
useful for documenting trends of a disease. HIV sentinel surveillance system was established
in 1994 among women who attend prenatal clinics, in-patients with tuberculosis and STD
patients, IDU’s, sex workers etc. All donated bloods are also screened for HIV since 1985.

156
 Confirm HIV/AIDS cases

Report using specific format

District Health Office

Submit summary using reporting format at the end of the month

State Health Office

(AIDS/STD unit)

Verify and merge reports from all districts and submit to the MOH

Ministry of Health (Section of

AIDS/STD)

Flow chart showing HIV/AIDS case reporting in the Ministry of Health Malaysia

National AIDS registry

The MOH established the net based national AIDS registry in 2009 to replace the existing
surveillance system. This registry captures data on each HIV patient along with his/her
socioeconomic background, treatment and other patient information.

Case Definition

Acquired Immunodeficiency Syndrome (AIDS)

For the purpose of epidemiological surveillance, an adult (>12 years of age) is considered to
have AIDS if tested positive for HIV antibody, and if one or more of the following is/are
present

 10% body weight loss or cachexia, with either intermittent or constant diarrhoea or
fever or both, for at least one month
 Cryptococcal meningitis
 Pulmonary or extra-pulmonary tuberculosis
 Kaposi sarcoma
 Neurological impairment that is sufficient to prevent independent daily activities not
known to be due to a condition unrelated to HIV infection (for example trauma or
cerebrovascular)

157
  Candidiasis of the oesophagus (which may presumptively be diagnosed based on the
presence of oral candidiasis accompanied by dysphagia)
 Clinically diagnosed life-threatening or recurrent episodes of pneumonia, with or
without etiological confirmation
 Invasive cervical cancer

Human Immunodeficiency Virus (HIV)

In adults, adolescents or children aged ≥ 18 months, a reportable case of HIV infection must
meet at least one of the following criteria

 Laboratory criteria
 Detection of antibody to HIV virus by a reactive result on a screening test for HIV
antibody (enzyme-linked immunosorbent assay), and followed by a positive result on
a confirmatory test (western blot) for HIV antibody in all patients except injecting
drug users.
 Detection of HIV virus (viral antigen) - Positive result or report of detectable quantity
on any of the following HIV virology (non-antibody) tests
o HIV nucleic acid (DNA or RNA) detection
o HIV p24 antigen test including neutralization assay and

 Clinical or other criteria (if the above laboratory criteria are not met). Conditions that
meet criteria included in the case definition for AIDS.

158
In a child aged < 18 months, a reportable case of HIV infection must meet at least one of the
following criteria

 Laboratory criteria
 Definitive positive result or report of detectable quantity on any of the following HIV
virology (non-antibody) tests:
o HIV nucleic acid (DNA or RNA) detection
o HIV p24 antigen test including neutralization assay

A child who does not meet the criteria for definitive HIV infection but who has a positive
result on only one specimen (excluding cord blood) using the above HIV virology (non-
antibody) tests

 Clinical or other criteria (if the above laboratory criteria are not met and there is no
other causes of immune suppression like autoimmune disorders, cancers etc.)

Condition that meet the criteria included in the 1987 paediatric surveillance case definition
for AIDS which are

 Candidiasis of the oesophagus, trachea, bronchi, or lungs

 Cryptococcus, extra pulmonary infection
 Cryptosporidiosis with diarrhoea persisting >1 month
 Cytomegalovirus diseases of an organ other than liver, spleen, or lymph nodes in
patient >1 month of age
 Herpes simplex virus infection causing a mucocutaneous ulcer persisting >1 month;
or bronchitis, pneumonitis, or esophagitis for any duration in a patient >1 month of
age
 Kaposi sarcoma
 Lymphoma of the brain (primary).
 Mycobacterium avium complex or M. kansasii disease, disseminated (site other
than/in addition to lungs, skin, cervical or hilar lymph nodes)
 Pneumocystis carinii pneumonia
 Progressive multifocal leukoencephalopathy
 Toxoplasmosis of the brain in a patient >1 month of age

159
  Two or more bacterial infections within a 2-year period (septicaemia, pneumonia,
meningitis, bone or joint infection) or abscess of an internal organ or body cavity -
excluding otitis media or superficial abscesses.

*it is important to keep in mind that criteria may change from time to time depending on the latest knowledge
and understanding of the disease as well as new screening and diagnostics tools

Notification

Under the Section 10 of the ACT 342, Prevention and Control of Infectious Diseases Act
1988, HIV (all forms) needs to be notified to the nearest Medical Officer of Health within a
week. Under the Section 10, Subsection (2) of the act, “every medical practitioner who treats
or becomes aware of the existence of any infectious disease in any premises shall, with the
least practicable delay, give notice of the existence of the infectious disease to the nearest
Medical Officer of Health in the form prescribed by the regulations made under this act”.
The notification needs to be done using a specific notification form as required by the
regulation under the Act 342.

In cases of death due to AIDS, District Medical Officer of Health must be informed by phone
for immediate measures that must be taken for burial arrangement. When the District Medical
Officer of Health is notified of a HIV/AIDS death he/she is responsible for initiating an
epidemiological investigation which will include the socio-demographic information and
laboratory reports. The investigation is done to gather comprehensive information concerning
the case and identify the probable mode of transmission and the source of infection as well as
to trace the contacts in order to prevent the spread of the infection.

Contact tracing

Contact tracing is done to prevent the transmission of HIV/AIDS. Contact tracing involves
identifying, tracing, counselling and informing the partner/contact(s) of the index HIV/AIDS
case of the risk of HIV infection. This is done ideally within 24 hours of the diagnosis of the
index case. The contacts are informed of the risk of HIV infection and counselled especially
on the prevention of transmission. They are emphatically told of the importance of being
tested for HIV. There are 2 methods of contact tracing

160
 1. Passive contact tracing: in this method the index case is advised to inform his/her
partner and persuade the partner to establish her/his HIV status through HIV
testing.
2. Active contact testing: is when upon notification, the district medical officer of
health instructs his team to verify the case and trace all contacts of the patient
within 24 hours. There is an urgent need to identify the contacts for early
diagnosis and for the prevention of transmission. Although the contact(s) may test
negative but they are informed of the ‘window period’ and hence the importance
of retesting and the prevention.

HIV Screening

Ever since 1985, the Ministry of Health, Malaysia has been actively involved in screening for
HIV. Screening is conducted to ensure the safety of blood used for transfusion and organs for
transplants and to monitor prevalence and trends of HIV infection over time in the population
(surveillance) and for early diagnosis and treatment. At present almost all government health
clinics including community clinics provide free HIV screening. HIV screening is mandatory
for all donated blood, blood products and organs, antenatal screening and routine screening of
inmates of drug rehabilitation centres and prisons, Tuberculosis and sexually transmitted
infected cases, clients of harm reduction programme etc.

HIV screening and testing is fundamentally based on international guidelines proposed by the
World Health Organization. Screening is planned according to the specific target groups -
low risk group, high risk group or for diagnosis purposes.

Rapid HIV testing using ELISA screening tests provide results in approximately 20 minutes.
This kind of test has been shown to be highly accurate (99.5%) and comparable to the blood
tests that are performed in a lab. However a positive result from a rapid HIV test must be
confirmed with a Western Blot performed in a lab. In government facilities screening tests
are conducted using rapid screening tests - Enzyme-linked immunosorbent assay (ELISA)
test and Particle Agglutination (PA) test, whereas the western blot or immunoblot assay is
only available at the National AIDS Reference Laboratory (NARL) in Kuala Lumpur and
certain university hospitals.

161
The current guideline in Malaysia requires all samples positive with Enzyme linked
Immunosorbent Assay (EIA) test be tested with another screening antibody test, namely
particle agglutination (PA). If both tests are positive, patient is regarded as “reactive”. In a
low prevalent population, supplementary test using Immunoblot is required for confirmation.
In high prevalent population e.g. among injecting drug users, only a repeat test of EIA and
PA will be required for confirmation.

When antibody test is neither positive nor negative it is considered as an

indeterminate/inconclusive result. This can occur because of
 recent HIV infection,
 prior blood transfusions, even with non-HIV infected blood,
 prior or current infection with syphilis, malaria, or other viruses,
 an autoimmune disease such as lupus or diabetes,
 being a recipient of an experimental HIV vaccine,
 or problems with the test procedure itself, such as contamination of the blood sample.

False negative result may be due to

 non-specific reactions in persons with immunological disturbance e.g.

systemic lupus erythematous (SLE) or rheumatoid arthritis (RA)
 multiple transfusions
 recent influenza or rabies vaccination.

A PCR (Polymerase Chain Reaction) test, also known as a "viral load" can be used during the
window period because it is able to detect the viral genetic material instead of detecting
antibodies.

162
Target groups for HIV screening

HIV screening is targeted for specific groups including

Screening high risk population – due to the nature of the infection which is transmitted
though infected body fluids, the following groups are screened

 Injecting drug users

 People with multiple sexual partners
 Commercial sex workers
 Clients of commercial sex workers
 Men who have sex with men
 Patients with STD’s
 Transfusion dependent patients (e.g. Thalassaemia, haemophiliac, leukaemia)
 Partners and contacts of the above people
 Inmates in the drug rehabilitation centres, high risk prisoners and home’s for wayward
girls

Screening of donated blood – since 1986 all blood or blood products which are donated for
the use for blood transfusion is screened to ensure it is safe. Only blood that is not reactive to
the test is used for transfusion. ELISA is used to screen the blood for HIV. If the initial test is
reactive it will be discarded and a repeat test is conducted and if needed a confirmatory test is
done. Once confirmed for HIV, the medical officer of health is notified.

To prevent transmission of HIV through blood donation, not only is the donated blood
screened for HIV, there are several other measures in place to prevent spread of infection via
blood donation.

1. The general public is educated concerning HIV transmission and specific

groups of people who engage in high risk activities such as IDU, men who
have sex with men, prostitutes or people with multiple sexual partners are told
not to donate blood.
2. All donors are required to declare that they are not involved in such high-risk
activities.
3. ‘Replacement donors’ are not encouraged although most of the blood donors
are volunteers

163
 4. A standard operating procedure is followed by all health care workers when
handling blood donation.

Antenatal HIV screening- antenatal HIV screening has been in effect since 1998 to prevent
mother to child transmission. HIV screening is conducted in all government health facilities
providing antenatal care. For expecting mothers who missed screening during their antenatal
period they are screened in the labour room. A pre and post screening counselling is
conducted. The pre-test counselling can be done by the allied health professional, however if
the rapid test is reactive, the Medical Officer is entrusted to counsel the patient before a
second blood sample is taken for confirmatory tests. HIV positive antenatal mothers are
treated with antiretroviral therapy until delivery after which the baby is also treated. ART is
given throughout the antenatal and intra-partum period. Infant is given treatment until 6
weeks of life and is followed up at regular intervals and is confirmed free of HIV at age of
two if the tests are still negative. The mother is advised against breastfeeding the child. It has
been reported that 75% of the risk due to vertical transmission can be reduced by these
interventions.

Voluntary HIV screening – groups of people who engage in high risk activities are
encouraged to go for voluntary HIV screening. Similarly a pre and post-test counselling is
done and the screening is conducted anonymously using a code as identification. A
confirmatory test is carried out if the initial rapid test is positive.

Premarital HIV screening- this is an Islamic religious department initiative which is aimed
at ensuring that couples planning to get married are aware of their HIV status. All Muslim
couples in Malaysia intending to get marred are required to undergo HIV tests before they are
allowed to marry.

164
 Pre- test counseling

Reactive ELISA/PA test Non -reactive

Sample Not Detected

verification* Post-Test counseling as HIV negative
case

ELISA/PA test Detected Post-test counseling as HIV positive case

*’Sample verification’ or second blood sample has to be taken one week after results of ELISA/PA is found to be
reactive/detected or otherwise informed by the lab that performed the test.

Work process for screening high risk patients for HIV/AIDS at a District level

Figure above shows the process of screening patients at a health clinic. The initial screening
test is done using ELISA/Particle agglutination test and if the sample is reactive, the second
blood sample is taken within a week. Post-test counselling is also provided.

Management of HIV/AIDS deaths

In a Hospital Ward
Once death of an AIDS patient occurs in the hospital ward, the nearest medical officer of
health and the next of kin is immediately notified and burial/cremation of the deceased is
done within 24 hours. Only minimal handling of the body is allowed with the handlers
required to wear two layers of protective gloves. The body is placed in a body bag, attached
with an identification tag and transported to the mortuary in a steel top trolley for
disinfection. The soiled linen is handled as little as possible, with minimal agitation and
bagged, properly labelled and sent to the laundry where it is disinfected with sodium
hypochlorite for 1/2 hour before being washed. Stretcher trolley, bed and other fomites that
come in contact with the body/body fluids must also be immediately disinfected with sodium
hypochlorite.

165
In The Mortuary
If not already done, notification is made to the nearest health office. All the handling
procedure is supervised by the ‘Penolong Pegawai Kesihatan Persekitaran’ (assistant health
officer). Handlers are required to wear personal protective gears (gloves, plastic aprons,
masks and rubber boots). The body and the clothing worn by the deceased are washed with
sodium hypochlorite (at least 20 minutes for clothing’s). Oral cavity or other orifices are
cleaned with a sponge holder (forceps) or other suitable instruments and plugged with cotton
wool soaked in sodium hypochlorite. The body is wrapped in cloth, and put into a translucent
body bag. In the case of a Muslim, white cloth is used and the body is further wrapped twice
more using a white cloth. The preparation area and items is disinfected with sodium
hypochlorite

Death in the House

In cases of an AIDS death in a house, the medical officer of health in the nearest district
health office is immediately informed. The number of people handling the body should be
kept to a minimum (not more than 5) and monitored by the assistant health officer (Penolong
Pegawai Kesihatan Persekitaran)/nurse. The body, the clothes, and any other items used are
disinfected with sodium hypochlorite before wrapped securely. The water used for washing
the body should be treated with chloride of lime before disposal. The body is then buried or
cremated according to the religious practice within 24 hours.

Transportation
For non-Muslims, the body is embalmed and put in fully sealed body bag/ translucent
polythene bag. The coffin which should be solid is sealed and placed in aluminium container
and sealed airtight. The coffin can only be opened under direct supervision of health
personnel.

Last rites
The last rites are done with minimal direct contact according to the religion and cultural
practices of the deceased and the burial and cremation should be done within 24 hours

166
Challenges in the Prevention and Control of HIV/AIDS

Lack of awareness and knowledge concerning HIV amongst the population leads to stigma
which may prevent or delay the procurement of advice and treatment. It is because of this that
the Ministry of Health actively challenges itself to be innovative in its prevention and
educational programmes. The ministry of health ensures that the access to HIV interventions,
including sexual and health services and education especially among the adolescents and the
high risk groups are easily available. With increasing influx of immigranst, especially the
illegal immigrants, there is a danger of undetected and subsequently untreated cases in the
country with the potential of transmitting the disease. Gender inequity and the possibility of a
prolonged and a devastating economic downturn may impede the control programes.
Globally the lack of innovation in newer HIV drugs and lack of access to second line ART
also poses a serious challenge in the fight against HIV/AIDS.

PROSTAR

Understanding that youths are in the most impressionable age, there is an urgent need to form
programmes that are especially custom made for them. With the knowledge that most youth
are easily influenced by their peers, the Ministry of Health Malaysia with the collaboration of
various agencies, developed PROSTAR or the ‘Program Sihat Tanpa AIDS Untuk Remaja’
to empower youths through knowledge enhancement and the adoption of healthy lifestyle
behaviours. The programme is fundamentally based on peer education. Peers are trained and
used as promoters of healthy lifestyles among youths - “From Youth, Through Youth, For
Youth”.

The objectives of the programme is to

 increase the awareness and knowledge regarding healthy lifestyles

 inculcate positive attitudes towards healthy lifestyle practices
 encourage youths to adopt healthy lifestyles and avoid unhealthy risk behaviours
 train peer educators that can influence other youth to practice healthy lifestyles and
 encourage volunteerism among youth which will eventually provide social support for
other youth

167
The participants are provided with information for action concerning healthy lifestyles,
relevant social issues, communication skills, and programme planning and high risk
behaviours. The increased awareness results in increased efforts to curb unhealthy lifestyles
among peers and empower youths to avoid risky behaviours and negative influences and
practice healthy lifestyles, maintain a healthy mind, engage in physical activities and practice
healthy eating habits which will eventually lead to a healthy life.

The programme is targeted at youths aged between 13-25 years old who are students and
school leavers, troubled youth like runaways, with disciplinary problems, history of substance
abuse and other high risk behaviours, and other marginalized group such as sex workers,
homosexual and transsexuals.

PROSTAR club

The PROSTAR club was established and registered on 30th of June 1997, with branches in
every state and district. The club network is run by its trained members consisting of mostly
teenagers. The activities of the club include AIDS education activities, outreach activities
and, publication and distribution of newsletters as well as other promotional activities such as
PROSTAR website.
There are numerous activities run by the club which include

 AIDS educational programme like exhibitions, speech/talks, publication and

circulation of materials, briefings, dialogues, forums, quizzes, essay writing, poster
drawing and educational visits
 club promotional activities like launching, membership drive and recruitment of new
members, competitions, advertisements and maintaining a PROSTAR website
 economic activities for the club like setting up stalls, charity shows, salon and cyber
café
 training activities like PROSTAR facilitator training, PROSTAR youth training,
PROSTAR school training, motivation, leadership training, religious/spiritual
guidance and counselling
 artistic activities like mural painting, poster drawing and ‘nasyid’, ‘dikir barat’,
sketches, poem recital etc.
 recreational activities like jungle trekking, caving, kayaking, beach activities,
mountain climbing, travelling, camping, sports and aerobics

168
 communication activities like problem solving, seminars, workshops, advice,
counselling, newsletters, bulletins
 social activities like group activities, foster family, health camps and tutorials,
outreach programme for troubled youths, PROSTAR service centres, AIDS education
and awareness programme, advice and support group.

169
 CHAPTER 8: VECTOR BORNE DISEASE CONTROL

Arthropods (an invertebrate with an external skeleton, a segmented body and jointed
appendages) transmitting diseases are called vectors. Vector-borne diseases are diseases that
result from infections transmitted to humans and other animals by infected blood-feeding
arthropods such as mosquitoes, ticks, and fleas. The vector does not cause disease itself but
spreads infection by conveying pathogens from one host to another, for example mosquitoes
that carry the malaria parasite or dengue virus, or rodent reservoirs of leishmaniais or
leptospirosis. A vector may be truly biological where the agent multiplies in the arthropod.
When the agent only multiplies in the vector it is called propagative cycle e.g. dengue virus,
it is called cyclo developmental if the agent has part of the life cycle in the vector e.g.
filiriasis and if the agent has a part of its life cycle and also multiplies in the host it is called
cyclopropagative type of transmission e.g. Malaria. The host wherein the sexual cycle occurs
is called the definitive host and the one wherein the asexual part of development takes place
is called the intermediate host. In vector borne infections there is usually one or more
intermediate host for transmission to occur. Vectors can also transmit diseases by mechanical
means by simply carrying the agent in or on its body from one host to another.

Pre malaria Eradication Programme

In 1953 Malaria eradication pilot project (MEPP) was started in Sabah followed by Sarawak
in 1956. In 1960 malaria eradication pilot project was launched by the Ministry of Health in
Peninsular Malaysia. This programme was started with the aid from the WHO to evaluate the
feasibility of carrying out a malaria eradication programme. The pilot project ended in 1964.
After evaluating the pilot project, Malaria Eradication Programme (MEP) was started in
Sabah and Sarawak in 1961 and in Peninsular Malaysia in 1967 .The Malaria Eradication
Programme (MEP) was established with the main aim of eradicating malaria by the year of
1982, but when it was found that the original objectives could not be achieved, with the
suggestion of the WHO, the malaria eradication programme was restricted to malaria control
programme.

170
Vector Borne Diseases Control Programme (VBDCP)
In 1981, at the start of the Fourth Malaysia Plan, the scope of MEP was expanded to cover
other vector borne diseases and this was implemented in three phases:
a. Phase 1 (1981-1982) – all eradication activities and malaria control services were
combined to form Anti Malaria Programme.
b. Phase 2 (1983-1984) – The Vector Borne Disease Control Program (VBDCP) was
established in 1983 in Malaysia. Dengue fever, dengue haemorrhagic fever and
filariasis were included under the VBDCP
c. Phase 3 (1985 onwards) – VBDCP was further expanded to include typhus, Japanese
Encephalitis, yellow fever and plague

At the beginning of the Fifth Malaysia Plan, in 1986, the prevention and control of vector
borne diseases in Sabah and Sarawak were incorporated into the programme. In the Sixth
Malaysia Plan the VBDCP was placed under the Disease Control Division. The Vector Borne
Disease Section then took charge of VBDCP.

Objectives of VBDCP
The objective of the VBDCP is to reduce the mortality and morbidity related to vector borne
diseases to a level where it no longer poses a public health problem and prevent the
occurrence of vector borne diseases in areas which are free of the disease and prevent the
reintroduction of plague, yellow fever, kala azar and chikungunya into Malaysia.

The following units were established by the ministry of health at the VBDCP headquarters at
the national level to achieve the objectives
1. Epidemiology and laboratory
2. Vector Control
3. Health Education and Training
4. Records and Documentation
5. Administration

The figure below shows the organisation chart of the Vector borne disease control
programme (2009) at three levels namely the national, state and district level and also a
fourth level known as the sectoral level (applicable for Sabah and Sarawak only). At the

171
National level the vector unit is chaired by the Director and Deputy Director who supervises
the activities of the State vector unit.

172
 Institute Of Medical Research Director WHO
advisors

National Public Health Institute

Deputy Director

Health Education &Training Epidemiology& Administration Record Vector Control

Laboratory

State Director of Medical& Health Services

State

Deputy State Director (Health)

Senior Medical Officer Of Health (Vector)

State Entomologist

Epidemiology&Laboratory Administration Vector Control (State Ento. Team) Health Education and Training

District Medical Officer of Health Airport and Seaport District Medical Officer

Senior Health Inspector

Health Inspector
Vector Medical Assistant Filariasis Control Team

Public Health Assistant Special Grade

Public Health Assistant Public Health Assistant Public Health Assistant Public Health Assistant
Malaria Control Unit (Sector Chief) Dengue Control Team) (Multi –Purpose Team)

Sector
Field Canvasser Spraying Team Public Health Assistant Public Health Assistant
(Special Team) (District Assistant)

Organisation chart for Vector borne diseases under Ministry of Health, Malaysia

173
The State vector unit is headed by the state director of medical and health services and the
deputy state health director who report to the deputy director at the national level. The
national and the state level vector units under the VBDCP consists of five subunits
Epidemiology and laboratory, Administration, Record section, Vector control unit and Health
education and training division. The state vector unit also consists of the senior medical
officer of health (Vector) and the state entomologist who supervises the activities at the
district level namely epidemiology and laboratory unit, administration, Vector control (state
entomology team) and health education and training at the district level. At the district level
there is a Medical officer of health for the airport and seaport who reports to the state deputy
director of health.

At the district level the head of the is the district medical officer and his team comprising of
the Senior health inspector, health inspector (vector unit), public health assistants special
grade and also a medical assistant (Filariasis control team). At the sectoral level (applicable
for Sabah and Sarawak) the activities of the VBDCP is manned by public health assistants
(Sector chief, Malaria control unit, Dengue control team and a Multipurpose team, District
assistant, special team, spraying team and a Field canvasser).

General functions of VBDCP at national level: - According to Kementerian Kesihatan

Malaysia (Cawangan Penyakit Bawaan Vektor, KKM, edisi 2009)
The VBDCP Headquarters has several important functions in co-ordinating the
implementation of activities under this programme. It is also one of the federal medical
institutions under the Ministry of Health of Malaysia.
a. Policy formulation – Forming and reviewing new policies and updating existing
policies from time to time.
b. Planning– overall planning including determining the scope, dimension, trend and
programme components. Specifying targets and identifying resources that are needed.
c. Setting standards and preparation of guidelines: set standards, determine indicators and
prepare guidelines for assisting the staff involved in implementing the programme
d. Coordinate VBDCP activities: coordinate the activities related to implementation of
VBDCP in the country, as well as the activities involved in the deployment of
manpower, identification of study projects, utilization of resources and giving technical
advice.

174
e. Management of resources – identify and get resources like health education materials,
spraying equipment and insecticides used for spraying.
f. Monitoring activities: monitor all the activities run by the state and other agencies.
g. Programme evaluation: once in 3 months evaluation is done for the activities run by
the VBDCP. Evaluation is also done at mid-term and at the end of every Malaysian
Plan.
h. Establishment of a documentation and reference centre including a vector museum:
collecting and updating reference materials and vector collectibles by the VBDCP
library and vector museum respectively
i. Cooperation among agencies: obtaining cooperation of agencies involved in VBDCP
j. Advisory service: provide technical advice to the states, institutions and agencies
concerning prevention and control of vector borne diseases.
k. Training: identify, plan and coordinate training needs and training courses by
coordinating with relevant institutions.
l. Operational research: planning, coordinating the operational research activities after
coordinating with the relevant authorities.

Units at the VBDCP Headquarters

1. Epidemiology and laboratory
The activities at the national and state level include
 Active case detection for malaria and filariasis control- For malaria control, the task
is carried out by health inspectors who obtain blood slides. For filariasis control, case
detection is done by health inspectors by obtaining blood slides and probe surveys
which are conducted in areas considered to have filariasis over the last one year period.
 Passive case detection for malaria- Here, case detections are through the medical and
health care facilities like Klinik Kesihatan and it is done on patients who are suspected
to have malaria and are receiving treatment from the hospital, health centres,
community clinic, midwives clinics, and primary health care posts.
 Mass blood survey for malaria control- This is carried out by a special team or
multipurpose teams which comprises of public health assistant and public assistant who
form two teams and conduct mass blood surveys at places reported to have an abnormal
increase in the number of malarial cases and in residential settlements of immigrant
workers who come from malaria endemic countries and aborigines living in the

175
 hinterland, and in places where focal outbreaks occur in non-malaria and malaria prone
areas.
 Laboratory diagnosis- to detect the disease and identify the parasites species using
peripheral smears.
 Treatment- full treatment is provided to all the positive cases. Hospital referral is
provided for all the complicated cases.
 Case investigation / case follow-up - all cases reported to VBDCP are investigated to
identify the source of infection or confirm whether it is an indigenous case and to
provide follow-up action.

2. Vector and larval control

Activities at the national and state levels
The vector control unit through the usage of entomological investigations and evaluation is
responsible for planning, coordinating, monitoring, reviewing and analysing the effectiveness
of vector control activities like spraying, source reduction using treated bed nets, use of
insecticides, anti-larval operations and law enforcement etc.
Activities at the district level
1. Geographical reconnaissance - like area mapping, house mapping is done by the public
health assistants (pembantu kesihatan awam) to help trace cases and facilitate activities like
spraying.
2. Spraying operations-
Malaria control is done to break the chain of transmission of the disease by exterminating the
vectors. Three types of spraying methods are used by the vector control unit i.e.
 Regular spraying done biannually in malaria prone areas,
 Special spraying done quarterly in land development schemes, timber camps, and
interior aboriginal areas.
 Focal spraying at malaria prone and non-malaria area whenever a case is reported.

For Dengue control, two types of fogging methods are used

1. Thermal fogging if a single case of dengue is reported
2. Ultra low volume fogging done during dengue outbreaks

176
Plague control is done by the eradication of rodents and fleas by the private sectors under the
supervision of the health department by fumigation using hydrogen cyanide and methyl
bromide. This fumigation is usually carried out on ships, godowns, and rodent breeding
places at sea ports and international air ports.

Anti-larval operations- Malaria control is done by spraying Abate 500E larvicide in earth
and cement drain rodding of subsoil drains and clearing of grass and weeds along the sides of
drains. This is also done at automatic siphons, tidal and sluice gates. The Automatic
siphon/drum sluice is used to catch water from flowing drain in a tap and release it at high
pressure. Agitation well prevents the water surface from being stagnant.

Picture 1 and 2: Automatic siphon/drum sluice

Picture 3: Agitation well

177
For dengue control, Aedes larva inspection is done from house to house, construction sites,
schools and in factories by looking for breeding places. And for Yellow fever control Ovitraps
and common breeding places including ports and international airports are checked at regular
intervals.

Entomological surveillance and investigation is based on the standard WHO entomological

methods are used to assess the effectiveness of insecticides in exterminating vectors and also
to study the habits of vectors.

3. Health Education and Training

Health Education
Health education is imperative in achieving the objectives of VBDCP. Several strategies are
employed to instil awareness among the public. These strategies include talks, small group
discussions, demonstrations and exhibitions. These strategies are employed during specific
periods, for example the dengue control health education activities are organized by the
vector control unit during the campaign months done every quarter of the year.

Training
All VBDCP staffs are given basic in-service training. At the national level the training is
carried out by the Institute for Medical Research (IMR) and the Public Health Institute
(Institut Kesihatan Umum). At the state level the training is carried out by the state vector
unit. At the local level it is carried out by the scientific officer of the vector unit to the public
health assistants.
An important strategy employed is the primary health care approach, where the people from
the community and the health care workers work together. Orientation training is provided to
volunteers who are chosen from among the community. The volunteers are taught to take
blood slides for malaria, provide health education and compile health records.

4. Records and Documentation

All VBDCP activities are recorded and documented at the sectoral (Sabah and Sarawak),
district, state and national levels. Records include epidemiological data, vector control, and
administration and health education activities. At the state level reports are compiled,
analysed and forwarded to the national level. At the national level the records are used as a

178
guideline to assess the achievements of the programme. The collected records are also
published and distributed as guidelines and guidebooks throughout the country.

5. Research
Two types of research are conducted by the IMR (entomology unit), the basic and operational
research. At the national level the VBDCP –HQ in cooperation with IMR does myriad of
research including the use of filarial and malarial drugs, effectiveness of insecticides etc. At
the state level Knowledge, Attitude and Practice (KAP) studies are conducted on various
aspects of the programme. They also test the effectiveness of insecticides.

6. Administration
Administration is important in order to have an efficient management and to coordinate
services, allocation of funds, preparation of budget, monitoring expenditure and logistics and
supplies of VBDCP.

179
Malaria

Malaria is a life threatening but curable and preventable disease caused by the
Plasmodium parasite, which is transmitted through the bites of infected female Anopheles
mosquitoes mainly between dusk and dawn. There are 4 types of plasmodium species with
different incubation periods which infect humans; Plasmodium Falciparum, Vivax, Ovale
and Malariae. Once the parasite enters the body, it multiplies in the liver and then infects
red blood cells. In recent years, human cases of malaria have occurred with Plasmodium
Knowlesi, a species which is found in the forests of South East Asia spreading mainly
through monkeys. Plasmodium falciparum can cause severe life threatening malaria. An
infected patient may be asymptomatic or mildly ill and infections are detected
identification of parasites in the blood. It is common for people to live through several
bouts of malaria and developing immunity to it. Infection due to Vivax malaria is also
called tertian infection because the fever spikes every 48 hours. The parasite in Vivax
malaria can become dormant in liver causing recurrent infections months apart. P.
malariae malaria is also slow to develop and is called Quartan malaria because the fever
spikes every 72 hours.

Epidemiology
Although malaria rates have decreased by 25% worldwide largely due to anti-malarial
control measures, some parts of the world it is still a major health problem. According to
the world malaria report 2011, there were about 216 million reported cases of malaria
worldwide. Malaysia is currently progressing towards its national goal to eliminate
Malaria by the year 2015 in Peninsular Malaysia and by 2020 in Sabah and Sarawak.
According to the WHO report, Malaysia is in the pre-elimination phase of Malaria control.
This can be attributed to the successful strategy of 100% confirmatory testing of all
suspected cases, mandatory reporting of detected cases, integrated vector management,
strong community participation in control activities, and training of volunteers from the
community as primary health care workers. According to the WHO, Malaysia can only be
said to have achieved a malaria-free status if there is no reported indigenous case in any
part of the country for three consecutive years. At present around 80% of malaria cases
occur in Borneo out of which 58% occur in Sabah. Less than 20% of the cases which
occur in Peninsular Malaysia are concentrated in the central, south eastern and northern
coastal regions. The commonest species spreading Malaria in Malaysia is P.vivax (57%)

180
followed by P.falciparum (25%), P.knowlesi (5%), and very few cases of P.malariae.
P.knowlesi is concentrated largely in Sarawak. Malarial infection mostly inflicts young
male Malaysian population, indigenous and jungle workers and those working in
agriculture related jobs and among those involved in outdoor activities. Immigrant
workers from Indonesia, Philippines and Myanmar form the bulk of imported cases.

Number of Malaria cases, 1961-2009

300000

250000
Number of cases

200000

150000

100000

50000

0
1961
1965
1970
1975
1980
1983
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Year

National Programme for Malaria Elimination Programme

The objectives of the programme is to reduce the morbidity and mortality of the disease by
eradication and control of Malaria with a purpose to prevent Malaria from becoming a major
health and social problem in Peninsular Malaysia and preventing the recurrence of malaria in
areas previously free from the disease (3 consecutive years with no indigenous malaria
registered or confirmed case). The objective is to reduce the incidence rate to less than 1
case/1000 population in Peninsular Malaysia by 2015 and reduce the incidence rate to less
than 1 case/1000 population in Sabah and Sarawak by 2017 and achieve 0% mortality. An
outbreak is defined as 1 indigenous case. Although declaration of malaria outbreak does not
typically depend on the number of imported cases reported, however, 5 or more imported
cases in the same area would raise suspicion that is significant enough to warrant an
investigation in the area.

181
Strategies
There are several strategies adopted to achieve these objectives; active case detection activity
in malarial areas and in places where there are no indigenous cases and screening of foreign
workers for malaria. Passive case detection is conducted in health clinics and hospitals and
vector control is done through micro stratification*- Stratification of areas endemic for
malaria into red, yellow and green zones for chemical sprays and other larvacidal measures.
Entomological monitoring is done through vector density and vector reproduction studies
(Cow trap or bare leg catch) and investigation of suspicious cases (PCR sampling for P.
Knowlesi species).
* according to the WHO, malaria stratification is defined as the process of uniting areas, populations or
situations that exhibit a relative resemblance of a set of specified relevant characteristics, thereby
distinguishing them from other areas, populations or situations dissimilar by the same set of characteristics.
Stratification is done by selecting from a group of variables considered as main determinants of the intensity of
malaria transmission like distribution of main vector species, altitude, temperature, humidity, rainfall and the
distribution of rural and urban population. Maps of the above variables are then overlaid with the maps
showing recorded malaria prevalence of past /recent surveys and also the data on malaria incidence from the
existing health facilities. The table below lists the recommendations of the WHO expert committee (17th
session.) Most country programmes including Ministry of Health Malaysia have made attempts to stratify their
malaria programmes.

Zone Criteria Spraying activity Bed Netting

Red Incidence>=1/1000 - Residual spray regularly 100% - Coverage 100%
- 6 / 3 months - Re-soak every 6 month
- 8 cycle - Ratio 1:2
- 8 cycles
Yellow Incidence < 1/1000 - Focal 100% & special spraying - Coverage 100%
- 6 / 3 months - Re-soak every 6 month
- Minimum 2 cycle until no case - 2 cycles until no case
for a year reported for 1 year
- Ratio 1:2 (1 mosquito net for
2 persons)
Green No local infection but - Focal 100% & special spray
the area is receptive 100%
and vulnerable i.e. there - 6 / 3 months
are foreign workers - Minimum 2 cycle until no case
with no signs and for a year
symptoms of malaria in -Implement active surveillance
the area, anopheles is measures
present but no parasite
has been identified
A red zone may change to yellow if there is no reported case of malaria in the area for four consecutive years
i.e. after 8 cycles of implementation of control measures. Similarly, a yellow zone may change to green if there
is no reported case of malaria in the area for one year i.e. after 2 cycles of implementation of control measures.

182
Activities at the National and State level
1. Epidemiology and laboratory
Active case detection for malaria control - the task is carried out by a health inspector who
obtains blood slides. Peripheral smear study for malarial parasites also known as the MP
(Malaria Parasite) test. Light microscopy of thick and thin stained blood smears remains the
standard method for diagnosing malaria. It involves collection of a blood smear, staining with
Giemsa stains and examination of the Red Blood Cells for intracellular malarial parasites.
Thick smears are 20–40 times more sensitive than thin smears for screening of Plasmodium
parasites, with a detection limit of 10–50 trophozoites/μl. Thin smears allow one to identify
malaria species (including the diagnosis of mixed infections), quantify parasitemia, and
assess for the presence of schizonts, gametocytes, and malarial pigment in neutrophils and
monocytes.
Passive case detection for malaria control- in all medical and health care facilities patients
who are suspected to have malaria and are receiving treatment are screened for malaria using
thin and thick blood smear.
Mass blood survey for malaria control- a special multidisciplinary team conduct mass
blood survey (public assistant and public health assistant in two groups) in places reported to
have an abnormal increase in the number of malarial cases, residential settlements of
immigrant workers who come from malaria endemic countries, aborigines living in the
hinterland, and where focal outbreaks occur in non-malarial and malaria prone areas
Laboratory diagnosis –parasites are identified using thin and thick blood smear
Treatment- full treatment is provided to all the positive cases at the health clinics and
hospital referral is made for all the complicated cases.
Case investigation / case follow-up -all cases reported to VBDCP are investigated to
identify the source of the infection or to confirm whether it is an indigenous case and for
follow-up action.

2. Vector control
The vector control unit through the usage of entomological investigations and evaluation is
responsible for planning, coordinating, monitoring, reviewing and analysing the effectiveness
of vector control activities. The activities conducted are spraying (focal spraying using abate),
treated bed nets, use of insecticides, anti-larval operations and law enforcement etc.

183
 3. Health Education
Methods like talks, small group discussions, demonstrations, exhibitions are used to instil
awareness among the public.

4. Training
All VBDCP staffs are given basic in-service training. At the national level the training is
carried out by the Institute for Medical Research (IMR) and the Public Health Institute (IKU).
At the state level it is carried out by the state vector unit.

5. Records and Documentation

All VBDCP activities are recorded and documented at the sectoral (Sabah and Sarawak),
district, state and national levels. Records include epidemiological data, vector control, and
administration and health education activities. At the state level reports are compiled,
analysed and forwarded to the national level and at the national level the collected records are
used as guidelines to assess the achievements of the programme.

6. Research
Two types of research conducted by the VBDCP - basic and operational research. At the
national level the VBDCP–HQ in cooperation with IMR does research in various aspects
including use of malarial drugs, effectiveness of insecticides etc. The Infectious Disease
Research Centre (IDRC) was established on 16th April 2001 to promote and conduct quality
research in the field of infectious diseases (especially those caused by emerging and re-
emerging infections) to aid in the management of the health problems of the country, and to
provide consultative services to health providers, managers and planners in the diagnosis,
treatment, prevention and control of infectious diseases. At the state level KAP studies are
done on various aspects of the programme and also to test the effectiveness of insecticides

Administration -Responsible for the management and coordinating services, allocation of

funds, preparation of budget, monitoring expenditure and logistics and supplies of VBDCP

184
Activities at the District Level

1. Geographical reconnaissance
Activities like area mapping and house mapping is done by the public health assistants to
help trace cases and facilitate activities like spraying.

2. Spraying operations
Vectors for malarial infection are killed to break the chain of transmission. Three types of
spraying methods are used by the vector control unit. Regular spraying is conducted
biannually in malarial infected areas. Special spraying is conducted quarterly in land
development schemes, timber camps and interior aboriginal areas and focal spraying at
malarial prone and non-malarial areas whenever a case is reported.

3. Mosquito and anti-larval operations

Larva control it is done by spraying Abate 500E larvicide or Lavarmate® in earth and cement
drains rodding of subsoil drains and clearing of grass and weeds along the sides of drains.
This is also done at automatic siphons, tidal and sluice gates.
Adult mosquito’s control
There are several adult mosquito control measures. Wall and indoor residual spraying is done
in a one km radius, every 6 months for 4 years. Impregnated bed nets with lambda-
cyhalothrin 2.5% is provided to houses in malarial prone areas. To determine the
appropriateness or otherwise of the dosage of insecticides used for impregnating the bednets,
the bednet is tested on cows to determine if the mosquitoes die when they touch on the
bednets. These nylon bed nets are re-impregnated every 6 months. Entomology investigation
on mosquito’s habitat is also an activity to control vector. Other activities to control the adult
mosquito is by bioassay test research on insecticide-resistant anopheles mosquitoes, fogging,
human or cow bare leg catching and the use of personal protective equipment including DDT
repellent, window screens etc. Bare leg catching is done by offering the human leg to the
mosquitos. It is usually done from 7pm onwards. The humans involved have already taken
prophylactic medication before taking part in this procedure. It measures the density and
species of mosquito in the house/area. A microscopic examination of the mosquito caught
during this process is done to determine the species. The species determines the type of
preventive measures to implement. For example, if the specie is anopheles, malaria

185
prevention and control strategy is implemented, while if it is culex Japanese Encephalitis
prevention and control measure is implemented. Index used is per man/per bite/per hour.
Biological Control using larvivorous fish such as guppy, panchax, gold fish and Siamese
fighting fish are also used as control agents. These fishes feed on the larvae.

4. Entomological surveillance and investigation: Standard WHO entomological methods

are used to assess the effectiveness of insecticides in killing vectors and also to study the
habits of vectors.

5. Health education and training

Discussions, lectures, demonstrations, exhibitions are used to instil awareness among the
public and training is carried out by the health district personnel themselves.

6. Primary Health Care Approach

This is an approach of getting the community to take ownership of controlling Malaria.
Volunteers are chosen from the community after obtaining approval of the local authority and
orientation training is provided to these people in activities like taking blood slides for
malaria, giving presumptive treatment, providing health education and compilation of health
records.

Monitoring
Malaria is a notifiable disease in Malaysia and all confirmed cases must be notified to the
District Health Office. Patients infected with P.Vivax are followed up for 12 months and
patients infected with other plasmodium species are followed up for 6 months. Malarial death
case is the ‘outcome indicator’ and is used as a ‘proxy’ to detect the effectiveness of the
malaria control program, which is the early detection of cases (active and passive detection),
complete treatment (chemoprophylaxis for malaria) and follow-up (all cases reported to
Vector unit are investigated to identify the source of the infection or to confirm whether it is
an indigenous case and to provide follow-up action).

Process of prevention and control of malaria at the state and district levels when a new
case is confirmed of malaria
Malaria cases are reported directly to the state health committee by filling up the notification
form or through e-notification within one week of confirming the case. From here the state

186
 health committee will direct the vector unit at the district level to conduct control and
prevention measures. After receiving the notification from the state, the vector unit will carry
out the investigative measures –spraying (focal spraying using abate), treated bed nets, anti-
larval operations and law enforcement. The infected person is followed up monthly and blood
test is conducted for a period of 6-12 months depending on the species of the mosquito, 12
months for P.Vivax and 6 months for other plasmodium species. Within a week the vector
unit will visit the area where the index case was residing. The patient, family members and
neighbours are interviewed to track the patient’s movement for the last 14 days to confirm
that the disease was contracted within that area. Preventive measures include health
promotion and education is done.

Malaria Chemoprophylaxis and Treatment

Treatment
Chloroquine is still the 1st line of treatment for P.Vivax in Malaysia
Dose: 25 mg base/kg for 3 days [10mg base/kg (max 600mg) stat, then 5mg base/kg (max
300mg) 6 hours later, day 2 and day 3]
Primaquine for treating hypnozoites
Dose: 0.5mg/kg (max 30mg) daily for 2 weeks. Check for G6PD deficiency before starting
the drug for mild cases – 0.75mg/kg (max 45 mg) weekly x 8 weeks
Special cases
Secondary Prophylaxis for Malaria in pregnant women – Chloroquine prophylaxis (300mg
weekly) until delivery followed by Primaquine post-delivery/post breast feeding.
1ST Trimester - quinine + clindamycin 7/7 (for P. falciparum) or Chloroquine (for other
species)
2nd Trimester and 3rd trimester – ACT (Artemisinin-based combination therapy)
Uncomplicated P.falciparum/P.knowlesi – Artemisinin-based combination therapy is
recommended

Chemoprophylaxis
Chloroquine phosphate – Prophylaxis using this drug is only applicable in areas with
chloroquine-sensitive malaria. Adult dose is 300 mg base (500 mg salt) orally, once/week.
The drug is taken 1 to 2 weeks before travel to malarial prone areas. The drug is taken weekly
on the same day of the week while in the malarial prone area and for 4 weeks after leaving
such areas. This drug may exacerbate psoriasis.

187
Doxycycline – can be used as prophylaxis in all areas. The dose is 100 mg orally. It is to be
taken 1 to 2 days before travel to malarial prone areas. The prophylaxis is to be taken daily at
the same time each day while in the malarial prone area and for 4 weeks after leaving such
areas. It is contraindicated in children <8 years of age and pregnant women

Mefloquine – it is used as a prophylaxis in areas with mefloquine sensitive malaria. One adult
tablet contains 228 mg base (250 mg salt) taken orally, once a week. It is started ≥2 weeks
before travel to malarial prone areas. It is to be taken weekly on the same day of the week
while in the malarial prone area and for 4 weeks after leaving such areas. It is contraindicated
in people allergic to mefloquine or related compounds (quinine, quinidine) and in people with
active depression, a recent history of depression, generalized anxiety disorder, psychosis,
schizophrenia, other major psychiatric disorders, or seizures. It is to be used with caution in
persons with psychiatric disturbances or a previous history of depression. This drug is not
recommended for persons with cardiac conduction abnormalities.

Malorone – is a prophylaxis which can be used in all areas. Adult tablets contain 250 mg
atovaquone and 100 mg proguanil hydrochloride. One adult tablet should be taken orally,
daily. It should be started 1 to 2 days before travel to malarial prone areas. The drug is to be
taken daily at the same time each day while in the malarial prone area and for 7 days after
leaving such areas. It is contraindicated in people with severe renal impairment (creatinine
clearance <30 mL/min). Atovaquone-proguanil is taken with food or a milky drink. It is not
recommended as a prophylaxis for children weighing <5 kg, pregnant women, and women
breastfeeding infants weighing <5 kg.

Limitations faced by the District health officers in the prevention and control of
Malaria
Foreign workers and illegal workers who are settled in remote and inaccessible areas like
hilly terrains are more prone to develop the disease but because of the language barrier and
their illegal status they usually refuse to take medical treatment and do not cooperate with
the health authorities leading to spread of the disease among the migrant populations. Poor
knowledge concerning the disease among the rural as well as aboriginal household is another
reason for the spread of the disease. Delay in seeking treatment due to their belief in
traditional medicine especially among the aborigines is a special concern. Apathy by the

188
community by disregarding the factors that cause breeding of the vector has led to an increase
in the breeding grounds of the mosquitos.

189
Microscopy of malaria parasites
Gametocyte of Plasmodium falciparum have a
crescent or banana shape

Schizont of Plasmodium vivax showing large number of merozoites. Also note the larger
size compared to normal red blood cell

190
 Gametocytes of Plasmodium malariae have a round
shape, about the size of the red blood cell. They have
fine granular appearance

Trophozoites of Plasmodium Knowlesi appear as ring of cytoplasm with chromatin dot and no
malaria pigment

191
Entomology

1. Life cycle of plasmodium species

The malaria parasite life cycle involves two hosts. During a blood meal, a malaria-infected female Anopheles
mosquito inoculates sporozoites into the human host (1). Sporozoites infect liver cells (2) and mature into schizonts
(3) which rupture and release merozoites (4). (Of note, in P. vivax and P. ovale a dormant stage [hypnozoites] can
persist in the liver and cause relapses by invading the bloodstream weeks, or even years later). After this initial
replication in the liver (exo-erythrocytic schizogony A), the parasites undergo asexual multiplication in the
erythrocytes (erythrocytic schizogony B). Merozoites infect red blood cells (5). The ring stage trophozoites mature
into schizonts, which rupture releasing merozoites (6). Some parasites differentiate into sexual erythrocytic stages
(gametocytes) (7). Blood stage parasites are responsible for the clinical manifestation of the disease.

The gametocytes, male (microgametocyte) and female (macrogametocyte) are ingested by Anopheles mosquito during
a blood meal (8). The parasites’ multiplication in the mosquito is known as the sporogonic cycle (C). While in the
mosquito stomach, the microgametocytes penetrate the macrogametocytes generating zygotes (9). The zygotes in turn
become motile and elongated (ookinetes) (10) which invade the midgut wall of the mosquito where they develop into
oocyts (11). The oocyts grow, rupture and release sporozoites (12) which make their way into the mosquito’s salivary
glands. Innoculation of the sporozoites into a new human host perpetuates the malaria cycle (1).

192
2. Laboratory reporting of malaria infection

Quantitative technique: For determination of parasitemia using thick and thin blood
films.

Thick smears:

The number of parasites/µl of blood is determined by enumerating the

number of parasites in relation to the standard number of WBCs/µl (8000).

No. Parasites × (8000 ÷ No. WBCs counted)

= No. parasites per µL of blood

Number of parasites can be reported for both asexual and sexual stages of the parasite
development. For example:
(i) Asexual type = 1250 (no. of parasites counted) X 8000
500 (number of WBCs counted)

= 20000 parasites per µL of blood

(ii) Sexual type = 250 (no. of parasites counted) X 8000

500 (number of WBCs counted)

= 4000 parasites per µL of blood

(iii) Report = Pf 20000/4000 per µL of blood

Thin smears:

The percent of infected RBCs is determined by enumerating the number

of infected RBCs in relation to the number of uninfected RBCs. A minimum
of 500 RBCs total should be counted

(No. infected RBCs ÷ Total No. RBCs counted) × 100

= Percent Infected RBCs
Notes:
• Multiply-infected RBCs are counted as one.
• Gametocytes are not figured in calculations.

193
Dengue

More than one-third of the world’s population live in areas at risk for dengue transmission.
Dengue infection is the leading cause of illness and death in the tropics and subtropics. As
many as 100 million people are infected yearly. Dengue is caused by any one of four related
viruses (DENV 1, DENV 2, DENV 3, and DENV 4) and is transmitted by aedes mosquitoes.
At present there is no vaccine to prevent dengue infection hence the most effective protective
measures are those that avoid mosquito bites. When a person is infected, early recognition
and prompt supportive treatment can substantially lower the risk of developing a severe form
of the disease.

Dengue remained a relatively minor, geographically restricted disease until the middle of the
20th century. The start of the Second World War and the advent of air transport led to the
coincidental transport of Aedes mosquitoes around the world in cargo led to the dissemination
of the viruses. Dengue Haemorrhagic Fever (DHF) was first documented in the 1950’s
during epidemics in the Philippines and Thailand. It was not until 1981 that large numbers of
DHF cases began to appear in the Caribbean and Latin America. Today about 2.5 billion
people, or 40% of the world’s population, live in areas where there is a risk of dengue
transmission. Dengue is endemic in at least 100 countries in Asia, the Pacific, the Americas,
Africa, and the Caribbean. The World Health Organization (WHO) estimates that 50 to 100
million infections occur yearly, including 500,000 DHF cases and 22,000 deaths, mostly
among children.

Dengue fever (DF) is caused by any of four closely related viruses, or serotypes and infection
with one serotype does not protect against the others, and sequential infections put people at
greater risk for dengue haemorrhagic fever and dengue shock syndrome (DSS). Dengue is
transmitted between people by the mosquitoes Aedes aegypti and Aedes albopictus, which
are found throughout the world. In many parts of the tropics and subtropics, dengue is
endemic and occurs during rainy season when the weather is optimal for aedes mosquito
breeding. Dengue epidemics occur when there are large number of vector mosquitoes, large
numbers of people with no immunity to one of the four virus types and the opportunity for
contact between the two.

194
 Models of Aedes egypti (left) and Aedes
.albopictus

195
Dengue in Malaysia

Dengue was reported in Peninsular Malaysia as early as 1901 which was followed by an
outbreak in Penang in 1902. Dengue became endemic in Malaysia in the 60’s and the first
laboratory diagnosis of Dengue haemorrhagic fever was done in the year 1962. In 1965
dengue was identified among paediatric age groups in Penang hospital. The first major
outbreak of dengue haemorrhagic fever with Dengue type 3 strain occurred in the year 1973,
this was followed by the second epidemic in the year 1982. Dengue is currently an endemic
disease in Malaysia and the outbreaks tends to occur in a cyclical pattern of every 8 years.

Incidence and case fatality rate of dengue, 2000-2009

200 0.7
180
0.6
160
Incidence rate / 100 000

Case Fatality Rate (%)

140 0.5
120 0.4
100
80 0.3
60 0.2
40
0.1
20
0 0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Incidence rate / 100 000 Case Fatality Rate

National Programme for Dengue

Dengue control is one of the important sections under Vector Borne Disease Control
Programme (VBDCP). The programme centres on disease surveillance and control, education
and awareness, inter‐agency collaboration and community participation, quality assurance,
research and training

The objective of the dengue control programme is to reduce the morbidity and mortality rate
of dengue fever and dengue haemorrhagic fever by controlling the disease vector – Aedes
mosquito. This can be done by identifying the density level of Aedes mosquitoes thereby

196
reducing the indoor and outdoor breeding of Aedes mosquitoes to an Aedes Index of below
1% and/or Bruteau Index of less than 5%. These efforts are made by encouraging community
participation in curbing the spread of dengue by educating the general public concerning
prevention and control of spread of dengue.

The strategies deployed to achieve the objectives include

 monitoring the incidence and death from dengue fever
 investigating all suspicious cases and taking preventive measures
 monitoring dengue endemic areas and areas where previous outbreaks have occurred
 fogging for registered or confirmed cases to eliminate the natural habitat of Aedes
mosquitoes
 public health promotion relating to Dengue fever and Dengue Haemorrhagic Fever
 co-ordination with other agencies and NGOs in dengue prevention and
 enforcement of the Vector Borne Diseases Act 1975

Implementation and Monitoring of the National programme

1. Disease surveillance and control
Epidemiological surveillance is done through prompt case notification within 24 hours of
clinical diagnosis via phone, fax or e-mail. Laboratory diagnosis is done by the use of rapid
screening tests and confirmation by standard laboratory technique. Clinical management is
improved through early case detection and quality assurance surveillance and audit.

2. Vector and larvae surveillance and control

Home surveillance is done by surveys conducted during home visits (Pemeriksaan
Pembiakan Aedes - PPA) and environmental surveillance. The aim is to cover at least 50
premises or 50m radius in one locality for each activity, both inside and outside the premises.

Fogging activity is another form of vector surveillance. The objective of fogging in vector
control is to achieve rapid extermination of adult mosquitoes in the affected area using safe
insecticides e.g. Malathion, Reslin and other pyrethroid /synergised pyrethroids. Fogs are
clouds of fine droplets (aerosols) of insecticide varying in size from 5 to 50 microns. They
are very small which enables them to be suspended in the air for long periods and penetrate
deeply into every part of the affected area. Fogs can be generated either thermally or

197
mechanically. There are two fogging methods which are employed – thermal and Ultra Low
Volume fogging.

Thermal fogging (Semburan ruang thermal- (SRT)) - a smoke generator is used to carry
insecticides (Gokilaht, Sumithion and Actellic) to the target areas. Thermal fogs contain
insecticides that are normally produced when a suitable formulation condenses after being
vaporised at a high temperature. Although water based solution can be used more but
commonly an oil-based solution (usually diesel) is used for fogging. The droplet size is
usually less than 15 microns, depending on the insecticide flow rate used. The machines
employ resonant pulse principle to generate hot gases (over 200C0) at high velocity. The
machine is meant for outdoor use and for enclosed spaces of 500 cubic feet or more, if the
area is smaller than a hand held thermal forgers is used (e.g. multi-storey buildings, slum
areas)

Picture showing thermal fogging equipment

Ultra Low Volume fogging (Semburan Ruang ULV - SRULV) – involves mechanically
generating aerosols using cold foggers. In this method a minimum volume of liquid
insecticide formulation (<500ml/hectare) is applied per unit area which provides maximum
efficiency in killing target vectors. Water-based solution is usually used in this method. The
droplet size is usually between 10- 15 microns, depending on the insecticide flow rate used.
The machine can be mounted onto the floor of a truck or a 4WD and used for field use.
Advantages of ULV fogging is that they don’t need costly diluents, use smaller volume of

198
insecticide thus eliminating storage and mixing problems, the droplet size is more uniform
(for effective killing) and it is non-volatile and lower pollution and less traffic hazard.

Though both methods are effective, thermal fogging is the method of choice used in the
following areas
1. Areas inaccessible by ground ULV
2. Multi-storey buildings
3. Godowns, warehouses
4. Covered drainage, sewers, septic tanks etc.

Fogging activities are carried out as soon as a suspected case of dengue is notified to the
health authority. For a single dengue case perifocal fogging 200m around the patient's house
is done using portable thermal fogging machine. In case of an outbreak, ULV fogging is used
to cover the whole locality. During dengue outbreak, the first round of fogging is normally
followed by a second application 7-10 days later. The two treatment cycle is based on the
life-cycle of the Aedes mosquitoes and the incubation period of the virus in the mosquito.
The outbreak is declared over once it has been possible to achieve a 20 day transmission-free
period.

Insecticides are chosen based on the safety to the people and the animals which come in
contact with the chemicals, the speed of its action, if it is strong enough to kill resistant
vectors, cost and the absence of ecologically damaging persistent residues. The insecticides
approved by the Ministry of Health for ULV fogging includes Aqua-K-Othrine and for
thermal fogging Actellic, Gokilaht or Malathion (4% active ingredient in final solution) and
for Larviciding Abate 500E, Abate 1% S.G and Lavarmate®. Traditionally, malathion was
the chemical of choice for dengue control. However observations and feedbacks by the
fogging teams indicated that the people did not accept fogging inside their houses due to the
foul smell of malathion and because of the oily residues left by the diesel-solvent on the
floors and walls of houses. Because of this, and the availability of more potent water-based
organophosphate and pyrethroid fogging formulations such as Actellic and Gokilaht, the use
of malathion is currently limited. The use of Abate larvicide on a large scale in high-risk
areas was also initiated in 1998 to reduce Aedes larval density. Similarly, larvicidal bacteria
(Bacillus thuringiensis subspecie israelensis – strain AM65-52) is used for larvae control in
areas near rivers/streams or large drains/water reservoirs where a case of dengue is reported.

199
Picture showing ULV fogging equipment mounted on a four wheel drive

All premixing is done in clean containers outside the machine and the formulation is properly
stirred and filtered before filling into the formulation tank of the machine. All fogging
operations are done depending upon the right weather conditions; provided it is not raining
and the wind speed is not too strong

200
 Condition Most Favourable Average Unfavourable

Time Late evening or early Early to mid-morning/late Mid-morning to mid

morning afternoon, early evening afternoon

Wind Steady between 3-13kph 0-3kph Medium to strong over 16kph

Temperature cool average High ground temperature

causing convection currents

Table showing the weather conditions favourable and unfavourable for fogging activities

A careful study of the street maps of the area is done prior to the start of the operation. The
residents are warned of the fogging operation beforehand so that the food is covered, fires are
extinguished, and pets are removed to safer areas together with the occupants. Upon arriving
at the fogging area the team assess the wind direction because fogging is usually done from
downwind to upwind (against the direction of wind). For vehicle mounted ULV or thermal
fogging machines fogging is usually done at right angles to the wind direction if possible.

Personal protective equipment like rubber gloves, boots, gloves, aprons and masks are worn
by the personnel in charge of fogging. They are provided with canvas boots, overalls and
caps with down turned brims with adequate soap for washing. For those engaged in ULV and
thermal fogging using Reslin or Malathion only overalls and masks are provided as the
hazard is very low. For those engaged in larviciding no special protective clothing is provided
as risk of toxicity from the insecticide is very low. Regular medical examination is advised
for determining blood levels of cholinesterase (if using organophosphate compounds) and
they are advised to report any symptoms of illness promptly to the supervisor.

Ovitraps are used to help monitor, control and detect Aedes and other mosquito populations
thus acting as an early warning signal to prevent any impending dengue outbreaks and
thereby help to control the Aedes mosquito population. Ovitraps are usually black cylinders
which attract female mosquitos to lay their eggs. The mosquitos from the hatched eggs are
unable to fly out of the device and die in it. Typically, ovitraps are given/set up immediately
after fogging operation. After 48 hours (during outbreaks) or one week (when there’s no case
reported), these ovitraps are examined to determine the number of ovitraps with positive
larvae. This indicates success or otherwise of the fogging operation.

201
Picture showing an ovitrap

Conventional indices are used to monitor the vector populations in dengue virus transmission.
The commonly used indices include House Index (HI), Container Index (CI), Breteau Index
(BI). These indices are based on the aquatic immature stages only and not the adult mosquito
population. The larvae are collected from different water holding containers infested with
larvae and pupae.

The House/Premise Index is used to monitor the immature stages of larva i.e. the percentage
of houses infested with larvae and/or pupae with one or more habitats for Aedes aegypti or
related species. The formula used is as follows

Aedes Index(A.I) Total number of positive house x 100

Total houses checked

202
The Container Index (CI) is the percentage of water holding containers infested with larvae
and/or pupae.

Container index Number of containers positive of breeding Aedes x 100

Total number of containers checked

The Breteau Index (BI) is the number of positive container per hundred houses inspected.

Breteau Index (B.I) Total number of positive containers x 100

Total number of houses checked

Among all the three indices, the House Index is most widely used to determine the presence
and distribution of Aedes populations in a given locality. However, the HI does not take into
consideration the number of positive containers per house. Similarly, the Container Index
(CI) only provides information on the proportion of water-holding containers that are
positive. On the other hand, the Breteau Index (BI) establishes a relationship between
positive containers and number of houses. Hence, the BI is considered as the most useful
single index for estimating Aedes density in a location.

There are several indices which are used to determine the extensiveness of distribution of
adult Aedes mosquitoes in an area,

Ovitrap index

Ovitrap index = Number of aedes positive ovitraps x 100

Number of ovitraps collected in specific area

Human bait used to calculate the landing rate/bait/hour. The mosquitoes thus collected can be
used for the virus Isolations.

Biting Rate Index = Number of female mosquito caught by bait

Amount of time (per hour)

House Index = Number of resting mosquito on home wall caught in 15 minutes

Number of houses

203
Other indices include
Larvae Density Index (LDI)

LDI = Number of larvae from all houses x100

Number of houses checked

Stegomyia Index (SI)

SI = Number of containers with larvae x 100

Number of residents in the area

Areas for vector control having a concentration of cases and /or high vector density are
labelled as priority areas for vector control. Special attention is also focussed in areas where
people congregate e.g. schools and hospitals. The priority areas are divided into these
categories

Priority 1: localities where an outbreak or a case of dengue has occurred in the past
Priority 2: localities with AI more than or equal to 5 % BI more than or equal to 20 %
Priority 3: areas with low aedes indices - AI less than 5 % and BI less than 20 %
Priority 4: Rural areas where there are no cases of dengue and the aedes indices are low

Anti-Larvae Operations
Larval survey on Aedes
After notification of a case in a locality the health inspector carries out an inspection of aedes
breeding sites. When only a single case of dengue is reported, all the houses within 200m
radius from the index house are inspected. If more than a single case is reported then all
houses within 400m radius is inspected within a period of 14 days and the investigation is
pursued as an outbreak investigation. During the survey each of the houses visited is checked
for the breeding sites for mosquito larva in the water containers inside the house. If larvae are
found breeding in the water containers then it will be collected by the health inspector in
sterile tubes and brought back to the district vector unit office where it will be checked for
species identification. Larval sampling is done in front of a witness i.e. the owner or the

204
occupant or the employee of the premise. If found guilty, the occupants can be charged a
maximum fine of RM 500 or given a warning letter, failure to comply will lead to a court
prosecution. For a high index case or an outbreak in which the Breteau index (B.I) > 5% and
the Aedes Index (A.I) > %1, a letter will be sent to the community leader to arrange a
community get-together clean up (gotong royong) in an effort to clean up the area.
Temephos SG (Larvacide) e.g. Abate crystalline will be provided if requested and appropriate
health education is provided to the residents of that area.

3. Health promotion and awareness

This is an important and an effective tool in the control of the transmission of dengue. The
health inspectors of the vector unit at the district level are involved in educating the
community on the prevention and control of vector borne diseases through talks, posters, and
pamphlets. These public health education activities are done with the involvement of the
community. Dengue Volunteer Inspection Teams (DeVITs) are volunteers selected by the
local community to help inspect areas in their community. Wide publicity is given on the
prevention and control of Aedes mosquito using the mass media though advertisements and
behavioural messages. Radio is the most common medium. These messages are disseminated
using the four major languages in the country (Malay, Chinese, Tamil, English). Community
participation in ‘gotong royong’ is encouraged especially in source reduction activities.
Source reduction activities are activities that eliminate unnecessary container habitats that
collect water such as plastic jars, bottles, cans, tyres, and buckets in which Aedes aegypti can
lay their eggs. To promote attention of the public, assistance is obtained from local leaders
and political dignitaries in launching exhibitions and in 'Search and Destroy' operations.

4. Communication-for-Behavioural-Impact (COMBI)
An innovative approach to planning and implementing social mobilization, known as
Communication-for-Behavioural-Impact (COMBI), was piloted in Johor State, with
assistance from the World Health Organization in 2001. Results from intensive monitoring
and evaluation suggest that the pilot project has contributed towards positive behavioural
outcomes. COMBI has now been adopted as the national approach to social mobilization and
communication for dengue fever prevention and control. COMBI involves five integrated
communication action areas which include public relations/advocacy/administrative
mobilization, community mobilization, sustained appropriate advertising, personal

205
selling/interpersonal communication/counselling, and point-of-service promotion. All
doctors, nurses and other staff in government clinics are required to carry out “point of
service promotion” by explaining the behavioural goals of the project to every patient who
came to the clinic for whatever reason. The private practitioners are also encouraged to
involve themselves in this service.

Dengue Outbreak

A dengue outbreak is classified when one of the following criteria is met

1. two or more registered or confirmed cases occurring not more than 14 days within the
same locality (without considering the total area covered by the locality, the outbreak
will only be from that one locality involved)
2. Two or more registered or confirmed cases occurring not more than 14 days in a 200 m
radius or 400m. (If two cases were detected in two separate localities, even though the
separation is only by a small road, the outbreak will be considered to be in two
localities)
3. Two or more registered or confirmed cases (without taking into account the distance of
separation), occurring not more than 14 days and share an epidemiological similarity or
relation (similarly if two cases were detected in 2 separate localities, even though the
separation is only by a small road, the outbreak will be considered to be in 2 localities)

During an outbreak, the operation room is activated. The members of dengue outbreak
operation room consist of the commander who is usually the District Health Officer, vice
commander usually the District Epidemiology Officer /District Senior Medical Officer,
secretariat, Assistant Senior Environmental Health Officer and members consisting of case
investigation team leader, vector control team leader, health education team leader,
enforcement team leader, supportive team leader (logistical and financial assistance), active
investigation team leader (ACD) and representative director of hospital.

206
CRITICAL STEPS CRITERIA
1. Prompt Notification All cases, including suspected cases, must be notified
within 24 hours of diagnosis.

2. Prompt Case Investigation All notified cases must be investigated within 24 hours
of notification.

3. Prompt and Proper Fogging 1st fogging to be carried out within 24 hours of
notification.

Fogging done between 6.30 - 8.30am, and between

5.30 -8.00 pm.

Coverage of premise fogged within an area of 400

meter radius

2nd fogging to be done within 7-10 days of 1st fogging.

Proper fogging procedure according to prescribed

guideline.

Proper insecticide preparation according to prescribed

guideline.
Table showing the activities of the of operation room during Dengue outbreak

Law Enforcement on Dengue

Destruction of Disease-Bearing Insects Act 1975 (Akta Pemusnahan Serangga Pembawa
Penyakit 1975 (akta 154))
In addition to health education, the ‘Akta Pemusnahan Serangga Pembawa Penyakit 1975’
provides the health personnel with the authority to take legal actions in the control of
mosquito breeding. This act states that
Without prejudice to the generality of the powers specified in subsection (1) the Director
General or a Medical Officer of Health or an inspector may in writing order the owner or
occupier of any premises to take or do any of the following measures or work:
a. To destroy disease-bearing insects wherever found
b. To collect and remove empty tins, cans, bottles or other receptacles in which disease-
bearing insects may breed
c. To cut down and remove any grass, bamboo stumps, fern or undergrowth in which disease-
bearing insects are likely to breed or harbour
d. To cover and keep continuously covered any tank, cistern, receptacle or other container
within the premises
e. To construct drainage of the premises

207
f. To fill up inequalities in the surface of the premises
g. To apply insecticide to any pond, well, pool or other body of water, vessel, stable, pigsty,
cattle shed, chicken coop or other place used for the shelter of animals
h. Generally to prevent the propagation or harbouring of disease-bearing insects

The Director General or a Medical Officer of Health or an inspector may in the same order
direct
1. The period within which the specified measures or work shall be taken or done or
completed
2.That the premises or any part thereof be closed until the specified measures or work are
taken or done or completed and the premises are no longer likely to propagate or harbour
disease-bearing insects
3. The intervals within which the specified measures or work are to be taken or done
4.That the specified measures or work are to be taken or done until the premises or anything
therein are no longer likely to propagate or harbour disease-bearing insects

Penalty
If found guilty of having breeding sites for mosquitos, a warning is issued to the occupants of
the premises to destroy the sites, if they fail to do so this will lead to the issuance of a
compound. The occupants may be compounded immediately not more than RM500 under the
Section 25, Destruction of Disease-Bearing Insects Act 1975. Failure to pay the compound
may result in the premise owner being charged in court. Depending on the frequency of the
offence, if prosecuted and found guilty for the first offence a fine of not more than RM10,000
or not more than 2 years of jail or both and for the second offence a fine of not more than
RM50,000 or a jail term of not more than 5 years or both under section 25(b), Destruction of
Disease-Bearing Insects Act 1975 may be handed down. The occupant may be fined RM500
each day until the source of breeding is destroyed.

Monitoring and Evaluation

A good reporting system is important to ensure early intervention in order to reduce the
incidence and mortality rates of dengue. All dengue cases have to be registered or recorded
daily or within 24 hours. The vector unit will updates all its records which is forwarded to
state health office and subsequently the Ministry of Health

208
Activities at the District Health Office

The general objective of the vector unit is to reduce the incidence of dengue to an extent that
it is not a public health problem in the area under the control of the district health office. The
ultimate objective is to eradicate the vector-borne diseases and to prevent the occurrence of
vector-borne diseases in currently non endemic areas. The specific objective is to achieve a
level of sanitation whereby the dengue vector breeding areas are reduced if not eliminated.

Dengue Control activities

The staffs update maps, graphs and charts and analyse data on vector-borne diseases
weekly/monthly and plan appropriate actions to be taken. The staffs in the district health
office are responsible to actively and passively detect cases. As soon as a case is notified an
epidemiological surveillance is conducted. Dengue is controlled through investigation of
cases and follow-ups and vector control is done through the reduction of vector breeding
sources, extermination of adult mosquitoes and larva by means of fogging and law
enforcement. Entomology surveillance involves the investigation of larva and adult
mosquitoes. Dengue control activities are conducted with the cooperation and collaboration
with other agencies to control/prevent dengue among specific population or specific area like
schools, and urban areas. Enhancing health education, including encouraging community
involvement in activities to control and prevent dengue is an important strategy to control
dengue outbreaks.

The figure below shows the process of control of dengue fever and dengue haemorrhagic
fever in the community at the district level. Based on previous incidences of dengue cases in
the area, the health officer of the vector unit makes a list of localities in the area which should
be targeted. If there are no cases reported in the locality then Aedes survey is conducted in
the targeted areas. If AI>1, the community representative is verbally informed followed by an
official letter relating to the findings and ultra-low volume (ULV) fogging is conducted
effectively within 24 hours and a ‘gotong royong’ is conducted with the community within 7
days. If a locality is found to have one dengue case then the health inspector of vector unit
receiving the case report, investigate the case within 24 hours. After identifying the place
where the infection was acquired, aedes survey and ultra-low volume (ULV) fogging is
effectively conducted within 24 hours. If AI>1, the community representative is informed

209
verbally and by an official letter and a ‘gotong royong’ is organized within 7 days to clean-up
the area. Aedes survey is repeated after the ‘gotong royong’ and if AI>1, it is repeated. If
more than one case is reported in the same locality an outbreak investigation is conducted.

210
 Activities of Prevention and Control of DF & DHF
Prevention activities/ No case
in locality
list of localities in the area
and target them
Aedes survey & larvaciding
in targeted localities
If AI>1, inform verbally and
by letter to community
representative/ JKKK etc
Thermal fogging / ultra-low
volume (ULV) fogging
effectively within 24 hours
Follow-ups of residents,
community cooperation to
clean-up areas, etc within 7
days
Repeat according to target
Flow chart of the activities at the district level vector unit after notification of a dengue case
Control activity of 1 case Control activities at
outbreak areas
Accept case report, investigate within
24 hours. Identify place where infection More than 1 case reported
is acquired. in the same locality within
14 days
Thermal fogging & ultra-low volume
(ULV) fogging effectively within 24
hours
Aedes survey & larvaciding within 24
hours
If AI>1, inform verbally and by letter to
community representative/ JKKK etc
Follow-ups of residents, community
cooperation to clean-up areas, etc
within 7 days
Effective thermal fogging & ultra low
volume (ULV) fogging every 7 days; 2
times for control of 1 case and
continued until outbreak is over
Repeat Aedes survey after clean-ups. If
AI>1, repeat clean-ups.
211
Diagnostic test for Dengue

NS1 Antigen Capture Elisa - NS1 antigen test (NS1 stands for non-structural protein 1)
allows rapid detection on the first day of fever, before antibodies appear some 5 or more days
later.
Virus Isolation – Virus isolation is the most reliable evidence of infection and is usually used
to detect antibodies. Virus isolation is usually done in the acute stage of illness (1 to 5days)

Dengue Prevention

There are numerous programmes organized by the ministry of health to prevent the
transmission of dengue. Dengue prevention campaigns are organized through national mass
media (television, radio and newspapers), new social media (Face book, Twitter, blogs),
advertisements on public buses and in bus stations, billboards at dengue hotspots, and posters
in schools etc. The public is also engaged via the mobile dengue interactive exhibitions and
advertising services in dengue problem areas. Data is from regional countries is monitored to
see the epidemiological trends. Ministry of health also collaborates with the WHO to
facilitate information sharing at the regional level by updating the regional dengue situation
every two weeks on its public website. A comprehensive annual report on the regional
dengue situation is published by an online journal, Western Pacific Surveillance and
Response, which enables countries to share information and also document field experiences.
With the help from the WHO Malaysia conducts the national evidence based Integrated
Vector Management training (IVM) workshops. The Asia-Pacific Network for Monitoring
Insecticide Resistance is another regional strategy to strengthen the regional information base
on disease vector susceptibility to insecticides. Regular external quality assurance
programmes are conducted to assure the quality of dengue diagnostic tests.

Dengue surveillance at the regional level

At the regional level, dengue surveillance, prevention and control are guided by two strategic
documents; the Asia Pacific Strategy for Emerging Diseases (APSED) 2010 and the Dengue
Strategic Plan for the Asia Pacific Region (2008–2015). These documents emphasize
sustainable integrated disease surveillance and evidence-based approaches for dengue
prevention and control.

212
Singapore and Malaysia collaborate to work together on cross-border surveillance. The
Environmental Health Institute of Singapore and the Ministry of Health of Malaysia have
jointly developed a web portal, UNITE Dengue (United In Tackling Epidemic Dengue),
which enables participating public health institutions in the Asia Pacific region to share case
and virus surveillance information, thus contributing to a better understanding of the
molecular epidemiology of dengue in the region.

Limitations of the dengue prevention and control programme at the district level

Existing vector control programmes are limited due to the cost, delivery and long-term
sustainability. Lack of community participation and interagency collaboration in activities
planned for the prevention and control of aedes e.g. Lack of participation in gotong-royong
activities, disinterest and indifferent attitude of the public towards keeping the premises clean
are a major hindrance to the success of dengue prevention programmes. Poor sanitation
causing people to dump trash in the drains leads to increased breeding grounds of the vector.
Poor cooperation from premise owners to health personnel’s during aedes survey is another
impediment to the success of the programmes.

213
Leptospirosis

Leptospirosis is a bacterial disease caused by the bacteria of the genus leptospira that affects
humans and animals mostly in tropical countries. The bacteria is spread through the urine of
infected animals. Cattle, pigs, horses, dogs, rodents and wild animals are examples of animals
that can be infected with leptospira. Infected animals may have no symptoms of the disease
and they may continue to excrete the bacteria into the environment ranging from a few
months up to several years. Humans become infected through direct contact with the urine
from infected animals or through water, soil, or food contaminated with the urine of infected
animals. The bacteria enter the body through the skin or mucous membranes. Drinking water
contaminated with the bacteria can also cause infections. Person to person transmission is
rare.

Epidemiology
Leptospirosis is considered as a re-emerging infectious disease and largely occurs in the
developing world. However data on the incidence and prevalence of leptospirosis is
unreliable due to underreporting in many parts of the world. High rates of infection have been
reported during heavy rainfall and flooding and among urban slum dwellers in areas with
poor sanitation. It is estimated that the annual incidence rate is >10 per 100,000 per year in
tropical countries. However the incidence varies considerably in countries especially due to
the reporting mechanisms available in these countries.

The first case to be officially reported in Malaysia was in 1925. The incidence rate in
Malaysia is estimated to be between 2 to 5 per 100,000 population although the incidence rate
has been shown to be on the rise recently. The incidence is higher among the men between
the ages 20 to 60 years of age. The case fatality rate is estimated to be around 10%. There is
also a high enzootic* incidence in the Malaysian domestic animal population. The humid
environment in Malaysia is an ideal environment for the growth of pathogenic Spirochaetes.
Persons who work outdoors or with animals, such as farmers, mine workers, sewer workers,
slaughterhouse workers, veterinarians and animal caretakers, fish workers, dairy farmers,
military personnel etc. and people who participate in outdoor activities are at higher risk. In
Malaysia, the outbreaks of leptospirosis are usually caused by exposure to contaminated
water usually during floods.

214
*non-human equivalent of endemic

National Programme for Leptospirosis

The objectives of the programme is to prevent and control leptospirosis outbreaks and reduce
morbidity and mortality associated with the leptospirosis by strengthening leptospirosis
surveillance and developing a mechanism for the effective control of leptospirosis

Strategies and implementation

1. Surveillance
Due to the increase in reported leptospirosis cases in the Malaysia, it is now a notifiable
disease in Malaysia under the Prevention and Control of Communicable Diseases Act 1988
since 2010. The State Health Departments compiles database on Leptospirosis by
surveillance especially on the possible source of infection. This data base is used to identify
the risk groups and help in the development of the leptospirosis prevention programmes.
Besides the socio-demographic data, information is collected on the clinical onset of the
disease, date of diagnosis, lab results and treatment, hospital where the treatment and the date
of notification. Other details collected include whether it was a sporadic case or an outbreak,
and method of spread of infection.

There are three types of surveillance programmes for the control of leptospirosis
a. Hospital-based surveillance:
Leptospirosis is suspected any in patient presenting with symptoms such as acute febrile
illness with headache, myalgia (particularly calf muscle) and prostration associated with any
of the following symptoms/signs - Conjunctival suffusion, anuria or oliguria, jaundice,
cough, haemoptysis and breathlessness, haemorrhages, meningeal irritation, cardiac
arrhythmia or failure and skin rash. Because the manifestations of leptospirosis are often
atypical, diagnosis is confirmed by laboratory test.
b. Sero surveillance (laboratory based surveillance)
The detection of persisting antibodies by Microscopic Agglutination Test (MAT) may give an
indication of the prevalence of Leptospirosis. Elisa tests provide information only on recent
or current cases and no information on the circulating serovars (serotype) because they use a
broadly reactive genus specific antigen for checking IgM antibodies.

215
c. Active surveillance
Provides valuable information on the "normal" incidence of leptospirosis in a community and
may identify serovars present in the area.

A Presumptive diagnosis is made by a positive result of a rapid screening test such as IgM
ELISA, latex agglutination test, lateral flow. Confirmatory diagnosis is made with the culture
of pathogenic leptospires, a positive PCR result using a validated method (primarily for blood
and serum in the early stages of infection). Fourfold or greater rise in titre or seroconversion
in microscopic agglutination test (MAT) on paired samples obtained at least 2 weeks apart. A
battery of Leptospira reference strains representative of local strains to be used as antigens in
MAT.

2. Case Management
A suspected case of leptospirosis is a case that is compatible with the clinical description and
a presumptive laboratory diagnosis. And a case is confirmed when the suspected case is
positive when tested using a confirmatory laboratory test.
Leptospirosis can be treated with antibiotics, such as doxycycline (2 mg/kg up to 100 mg 12-
hourly for 5-7 days), tetracycline or ampicillin or amoxicillin, which should be given early in
the course of the disease. Third-generation cephalosporin’s such as ceftriaxone and
cefotaxime, and quinolone antibiotics are also be effective. Intravenous antibiotics e.g. like
IV benzyl penicillin (30 mg/kg up to 1.2 g 6-hourly for 5-7 days) are used for persons with
more severe symptoms.

3. Outbreak Response
An outbreak of leptospirosis is considered when there is more than one probable or confirmed
cases of leptospirosis with an epidemiological link with one incubation period. All outbreaks
must be notified to National Crisis Preparedness and Response Centre (CPRC) KKM by
phone or text to on-call surveillance. And all outbreak preliminary reports must be sent to the
CPRC, Disease Control Division by e-mail or fax using specific forms within 24 hours. The
source must be identified and appropriate environmental measures implemented and
information given to people at risk (including clinicians and health care workers and health
authorities). A final report must be produced after one month the outbreak ends and to be sent
to CPRC, Disease Control Division

216
 Case Notification

Case Investigation

Positive Investigation Results

Prevention and Control Measures

Registration in E-notification

Outbreak identified

Notified to CPRC KKM by phone or text to

on-call surveillance Outbreak Control

Send Report to CPRC within 24 hours

Send Daily Report/ Progress Report

Send Final Report to CPRC, KKM within one

month after the Leptospirosis outbreak ends
officially

Flow Chart on the handling of Leptospirosis Outbreak at the district level

217
4. Prevention
The preventive measures are based on the level of knowledge of the audience. These
preventive measures include identifying and controlling the sources of infection e.g. open
sewers, contaminated wells and the control of faecal reservoirs. Areas such as water
sources/bodies are assessed and marked with increased risk exposure using warning signs.
The public is advised to keep their homes and premises free from rodents. In cases where
there is a possibility of infection or disease in human hosts, antibiotic prophylaxis is given
usually doxycycline 200mg in one weekly dose however this is not routinely used. Health
education and raising awareness of the disease and it’s modes of transmission is disseminated
and people are advised to vaccinate their pets against leptospirosis. Cleanliness at the
recreational areas, food premises as well as housing area is promoted. As in all other
preventive measures there is interagency collaboration with local authorities, Wildlife
Department (PERHILITAN), Department of Veterinary Services (JPV), National Training
Service Department (JLKN) etc. to maintain cleanliness in the respective environmental
settings, especially rodent control. Persons with occupational or recreational exposure to
potentially contaminated water or soil are advised to wear waterproof protective clothing
such as rubber boots and gloves, cover skin lesions with waterproof dressings, wash with
clean water immediately after exposure and to seek immediate medical treatment if develop
symptoms within the incubation period.

Limitation
There are several challenges in the prevention and control of leptospirosis infection. There is
a general lack of awareness of the people and medical professionals concerning the disease.
Another major impediment to the early diagnosis of the infection is the unavailability of
laboratory support for diagnosis. There are now several rapid test kits which have become
available in the market in the recent years. However, there is no uniform standard or
algorithm for laboratory diagnosis. Currently available leptospirosis country data for
Malaysia is based on the Report of Morbidity and Mortality for Ministry of Health Hospitals
but because these cases were from hospital records, it is not known whether they were
sporadic cases or related to clusters.

218
Filariasis

Lymphatic filariasis, considered globally as a neglected tropical disease, it has been identified
by the World Health Organization as the world’s second leading cause of permanent
disability. It is a parasitic disease caused by microscopic, thread-like worms Wuchereria
bancrofti, Brugia malayi and B. timori. The adult worms only live in the human lymph
system. Lymphatic filariasis is spread from person to person by infected mosquitoes
(Anopheles and Culex). These parasites develop into adult worms in the lymphatic vessels,
causing severe damage and swelling (lymphoedema). Elephantiasis is painful, disfiguring
swelling of the legs and genital organs, a classic sign of late-stage disease.

Epidemiology
It is estimated that 120 million people in tropical and subtropical areas of the world are
infected with lymphatic filariasis. Almost 25 million men have genital disease and almost 15
million, mostly women, have lymphedema or elephantiasis of the leg. Approximately 66% of
those at risk of infection live in the WHO South-East Asia Region and 33% in the African
Region.

In Peninsular Malaysia, Kedah, Pahang, Kelantan and Terengganu are the states known be
have higher incidence of filarial cases whereas in East Malaysia both Sabah and Sarawak are
endemic for filariasis.

Diagnosis
The standard method for diagnosing active infection is the identification of microfilariae in a
blood smear by microscopic examination. Because the microfilariae that cause lymphatic
filariasis circulate in the blood at night (called nocturnal periodicity), blood collection is done
at night to coincide with the appearance of the microfilariae. A thick smear is prepared and
stained with Giemsa or hematoxylin and eosin. For increased sensitivity, concentration
techniques can be used.
Serologic techniques provide an alternative to microscopic detection of microfilariae for the
diagnosis of lymphatic filariasis. Patients with active filarial infection typically have elevated
levels of antifilarial IgG4 in the blood and these can be detected using routine assays.

219
Because lymphedema develop many years after infection, lab tests are most likely to be
negative with these patients

Treatment
Although the infection can be treated with drugs, chronic conditions may not be curable by
anti-filarial drugs and require other measures, e.g. surgery for hydrocele, care of the skin and
exercise to increase lymphatic drainage in lymphoedema. Diethylcarbamazine (DEC) which
is the drug of choice, kills the microfilaria and some of the adult worms. DEC has been used
world-wide for more than 50 years. Another treatment option is ivermectin, which kills only
the microfilariae. Annual prophylaxis of all individuals at risk (individuals living in endemic
areas) with recommended anti-filarial drug combination of either diethyl-carbamazine citrate
(DEC) and albendazole, or ivermectin and albendazole; or the regular use of DEC fortified
salt can prevent occurrence of new infection and disease.

Prevention & Control

The best way to prevent lymphatic filariasis is to avoid mosquito bites (for Brugia malayi and
Wuchereria bancrofti). The mosquitoes that carry the microscopic worms usually bite
between the hours of dusk and dawn. People living in endemic areas are advised to sleep in
an air-conditioned room or under a mosquito net especially between dusk and dawn, wear
long sleeves and trousers and use mosquito repellent on exposed skin. Another approach is to
give entire communities Diethyl carbamazepine that kills the microscopic worms. And most
importantly, the elimination of mosquito breeding areas.

The Global Programme to Eliminate Lymphatic Filariasis

WHO has declared filariasis as an eradicable or potentially eradicable disease since 1997.
Global programme to eliminate lymphatic filariasis was started in the year 2000. Elimination
is defined by mf rate of <1% and <1/1000 infected children for five cumulative years. The
elimination strategy has two components
1. To stop the spread of infection by interrupting transmission.
2. To allay the suffering of affected population (controlling morbidity).

220
In order to achieve the 1st strategy, endemic areas are mapped and community-wide mass
prophylaxis treatment to the population at risk is done. This is performed once yearly with the
administration of a single dose of the two drugs mentioned earlier.

The following regimens are recommended once a year for at least 5 years with coverage rate
of 65% of the total at risk population.
 6 mg/kg of body weight diethylcarbamazine citrate (DEC) + 400 mg albendazole or
 150 µg/kg of body weight ivermectin + 400 mg albendazole (in areas that are also
endemic for onchocerciasis).

In endemic regions usage of common table salt or salt fortified with DEC given for a period
of one year was found to be equally effective. In Malaysia, the target year for elimination was
2013.

Filiarisis Control Program

The objective of the programme is to detect and treat every filariasis case to reduce its
incidence and morbidity.
Strategy
An important strategy employed is the early laboratory diagnosis using the ‘thick smear’
technique and treatment for people living in endemic areas. The health department has also
increased cooperation between agencies especially those related to foreign workers.
Activities
A filariasis control team conducts house and population census, mass blood surveys and
treatment of confirmed cases. Individual cases are followed up once in every 3 to 5 months,
and the areas of outbreak are resurveyed after a period of 2 to 3 years. A team from vector
control unit visits endemic areas and screen populations at high risk e.g. orang asli
settlements, foreign workers at construction sites. Filariasis screening is usually done
alongside malaria screening.
Blood surveys are carried out from house to house at night usually 9 pm. 20mm³ of blood is
collected from each individual via a finger prick test to develop a thick smear. This smear is
dried overnight and stained with dilute Giemsa stain. The type of species and number of
microfilariae present are recorded from the blood films. Each individual in the outbreak area

221
is given a dose of 5mg of diethylcarbamazine citrate/kg, with the dose titrated by body
weight. To ensure the treatment is taken health workers will directly observe the consumption
of the medication immediately. Similar supervised doses are given at weekly intervals up to a
total of 6 doses, to complete the treatment course with a total dose of approximately
30mg/kg. Follow up blood surveys are made at varying intervals after the initial mass
treatment, normally within a period of about 2 years. For vector control, thermal and ULV
fogging is done. Anti-larvae control activity is done by conducting larva survey and
larviciding activities.

Microscopic features of filarial worms

Microfilaria of Brugia Malayi showing a tapered or flattened tail (terminal papillae) with a
significant gap between the terminal and sub-terminal nuclei.

222
 Microfilaria of Wuchereria Bancrofti showing a gently curved body and a loosely
packed nuclear column (the cells that constitute the body of the microfilaria

Lifecycle of Brugia Malayi

223
Chikungunya

Chikungunya is a viral disease that is spread by mosquitoes. The disease commonly occurs in
Africa, Asia and the Indian subcontinent. However recently there have been reported cases in
Europe and the Americas. Chikungunya virus (CHIKV) is a member of the genus Alphavirus,
in the family Togaviridae. It causes fever and severe joint pain. Other symptoms include
muscle pain, headache, nausea, fatigue and rash. The disease shares some clinical signs with
dengue, and can be misdiagnosed in areas where dengue is common. At present there is no
cure for the disease and treatment is focused on relieving the symptoms.

Epidemiology
Chikungunya virus infection is a re-emerging disease in Malaysia. Recent outbreaks in
Malaysia have been reported in Port Klang in 1998-99 and Bagan Panchor in april 2006. No
fatalities have been recorded due to chikungunya. It is believed that there is a low level
continued transmission of the disease and due vagueness of the symptoms there is a failure to
detect this disease. Immigrants from endemic countries like Thailand, Indonesia and India
could also have inadvertently brought the disease here.

Transmission
The virus is transmitted from human to human by the bites of infected female Aedes aegypti
and Aedes albopictus mosquitoes. Although the mosquitoes are active in the early morning
and late afternoons they do bite throughout the daylight hours. After the bite of an infected
mosquito, onset of illness occurs usually between four and eight days but can range from two
to 12 days.

Diagnosis and treatment

Laboratory diagnosis is done using serological tests like ELISA (enzyme linked
immunosorbent assay). There is no specific treatment for the disease, treatment is usually
symptomatic to relieve symptoms like joint pains.

224
Prevention and control
At present there is no vaccine for chikungunya. Prevention and control depends on
eliminating mosquito breeding sites. Same strategies employed to control dengue fever
outbreaks are employed to control mosquito and larvae of aedes mosquitos.

225
Japanese Encephalitis
Japanese encephalitis is a viral disease that infects both animals and humans. The flavivirus
causing Japanese encephalitis is transmitted by mosquitoes belonging to the Culex
tritaeniorhynchus and Culex vishnui groups, which breed particularly in flooded rice fields.
JE causes inflammation of the membranes around the brain.

Epidemiology
Japanese encephalitis is a leading cause of viral encephalitis in Asia with 30,000-50,000
clinical cases reported annually. It occurs from the islands of the Western Pacific in the east
to the Pakistani border in the west, and from Korea in the north to Papua New Guinea in the
south. In Malaysia, between 9 and 91 cases of JE are reported each year with most human
cases reported in Sarawak. The peak season is October to December in Sarawak.

Diagnosis and Treatment

JE virus detection is based on laboratory tests measuring specific antibodies against JE virus
in the cerebrospinal fluid or in the blood. Specific antibodies can be measured within 4 to 7
days of onset of the disease. Alternatively, the virus itself may be recovered in special cell
cultures inoculated with blood or cerebrospinal fluid collected in early stages of the disease.
Therapy for symptomatic Japanese encephalitis virus (JEV) infection is supportive. Patients
often require feeding, airway management, and anticonvulsants for seizure control. No
significant effective antiviral agents exist.

Prevention and Control

Although there is an effective vaccine available for Japanese encephalitis, but it is expensive.
It requires one primary vaccination followed by two boosters. Because of the breeding places
are difficult to access and extensive chemical vector control is not a solution, Personal
protection (using repellents and/or mosquito nets) are effective under certain conditions.

226
Though VBDCP was further expanded to include typhus, yellow fever and plague since 1985,
as the diseases are very uncommon amongst the Malaysian population the following
recommendations are based on guidelines by WHO

Yellow Fever

Yellow fever a viral haemorrhagic fever commonly occuring in tropical and subtropical
areass and is transmitted to humans from the bite of an infected female aedes mosquito
carrying arbovirus of the flavivirus genus. Yellow fever disease may be mild self-limited
febrile illness to severe liver disease resulting in haemorrhagia. Diagnosis of Yellow fever is
based on symptoms, physical findings, laboratory testing, and travel history. Once contracted,
the virus incubates in the body for 3 to 6 days, followed by an infection that can occur in one
or two phases. In the "acute" phase usually patients complains of fever, muscle pain with
prominent backache, headache, shivers, loss of appetite, and nausea or vomiting. Although
most patients improve and their symptoms disappear after 3 to 4 days, 15% of patients enter a
second, the more toxic phase, within 24 hours of the initial remission. The patient usually
has high fever and he may rapidly develop jaundice and also may complain of abdominal
pain with vomiting. Haemorrhagic yellow fever is life threatening and may be fatal.
Diagnosis is clinical and laboratory diagnosis is by testing serum to detect virus-specific IgM
and neutralizing antibodies. Treatment is usually symptomatic. Prevention is by vector
control and education and vaccination. Vaccination is effective and has played an important
role in the control of yellow fever. The WHO recommends vaccination for all travellers to
areas with endemic or transitional yellow fever risk. In Malaysia proof of vaccination is
required for travellers ≥1 year of age arriving from countries with risk of Yellow fever virus
transmission and for travellers who have been in transit for >12 hours in an airport located in
a country with risk of Yellow fever virus transmission.

227
Plague

It is caused by the bacteria named Yersinia pestis. Humans are infected from the bite of
infected fleas living on rodents like rats. Humans bitten by an infected flea may develop
bubonic form of plague or the deadlier pneumonic plague. Diagnosis is by either clinical or
laboratory. Depending on the presentation of the plague, bubo aspirates, blood, and sputum
are the most appropriate specimens for rapid testing and culture. B. pestis may often be
isolated in culture from the tissues (bubo, liver, spleen, or heart's blood) of an infected rat.
Serum taken during the early and late stages of infection can be examined to confirm
infection. Rapid dipstick tests have been validated for field use to quickly screen for Y. pestis
antigen in patients. Treatment includes using antibiotics (Ciprofloxacin, Doxycycline,
Streptomycin, Chloramphenicol) and supportive therapy. Vaccination is only recommended
as a prophylactic measure for high-risk groups (e.g. laboratory personnel who are constantly
exposed to the risk of contamination)

Scrub typhus

Scrub typhus is common in the western pacific region and many parts of Asia. The risk
factors of Scrub typhus are closely related to occupation, most cases in Asia are acquired
through agricultural exposure. It is transmitted from the bite of an infected chigger. The
incubation period is 5 to 20 days after the initial bite. Diagnosis is made on clinical grounds
and laboratory test. The usual clinical symptoms include fever with chills, headache,
conjunctivitis and swelling of the lymph nodes. Although the Weil-Felix test is the cheapest
and most easily available serological test but this is also very unreliable test. There are some
rapid diagnostic kits but they are expensive. ELISA has been shown to be fairly reliable. The
gold standard is indirect immunofluorescence antibody. Treatment of the disease is by usage
of antibiotics like Tetracycline, Chloramphenicol, and Doxycycline etc. there are no vaccine
available for scrub typhus but a single dose of oral chloramphenicol or tetracycline given
every five days for a total of 35 days with a 5 day non-treatment intervals. Preventive
measures include public education, rodent control and early case detection

228
 CHAPTER 9: NON COMMUNICABLE DISEASES

A Non-communicable disease (NCD) is a disease which is not infectious. It is usually chronic

and has a slow progression. According to the WHO fact sheet NCD kills more than 36
million people each year, most of which are premature deaths in mostly low and middle
income countries. The four major causes of NCD deaths are cardiovascular diseases, cancers,
respiratory diseases and diabetes. The major risk factors for these illnesses are tobacco use,
physical inactivity, alcohol abuse and poor dietary habits.

Epidemiology
Approximately 17 million Malaysians or 60.7% of the population are living with non-
communicable diseases (NCD). Ministry of health Malaysia reported that an estimated 2.6
million people are living with diabetes mellitus, 5.8 million with hypertension, 6.2 million
with high cholesterol and 2.5 million are obese. 63% of Malaysians had at least one
cardiovascular risk factor, 33% had two risk factors and 14% had three or more risk factors.
Hypertension remains the number one risk factor with a prevalence rate of 43% in adults
above 30 years of age, followed by central obesity (37%), hypercholesterolaemia (24%) and
hyperglycaemia (15%). According to the NHMS survey (2011) the prevalence of NCD risk
factors in Malaysia continues to rise. 2.6 million adult Malaysians have diabetes, 5.8 million
have hypertension, 6.2 million have hypercholesterolemia and 2.5 million have obesity. NCD
is the main cause of premature deaths among adults in Malaysia. The disabilities and
premature deaths caused by these diseases have serious economic consequences on the
population. The increasing medical cost to treat patients with NCD is of a major concern to
the government. According to a study conducted among adult Malaysians showed the
prevalence of smoking among the adults Malaysians was a staggering 46.5%. It reported that
the mean age of starting to smoke was 18 years old. The prevalence was highest among the
Malays.

According to the Disease Burden Study conducted in the year 2004 (using 2000 data) that
took into account both mortality and morbidity, the eight leading burden of disease in
Malaysia, ranked from the highest to the lowest are ischemic heart disease followed by
mental illness, cerebrovascular disease/stroke, road traffic injuries, cancers, asthma & chronic

229
obstructive pulmonary diseases, diabetes mellitus and certain infectious diseases of major
public health problems. Findings from the National Health and Morbidity Survey (NHMS)
and the First Malaysian NCD Risk Factor Survey 2005/2006 show that NCD and NCD risk
factors are increasing at an alarming rate in Malaysia.

Malaysia’s Response to the Epidemic

The increase in the prevalence of NCD’es in the country has increased the demand to the
health care resulting in an increase in the costs of treatment. This prompted the Malaysian
government in its tenth Malaysia plan 2011-2015 to initiate strategies to promote healthy
lifestyles among its citizens. The government created an environment that promotes wellness
and healthy living and empowering communities to maintain their health individually and
collectively. In the 10th Malaysia plan the government organized healthy lifestyle campaigns
targeting school children, adolescents, women and the elderly. These campaigns emphasized
healthy eating, physical activity, anti-smoking and mental health. In this 10th Malaysia plan,
sports and recreational activities were encouraged by building, upgrading and maintaining
sports and recreational facilities and making them easily accessible. The government made
compulsory for students to participate in at least one sports activity.

Malaysia has made a head start in the prevention and treatment of NCD by placing the
emphasis on the primary prevention and early NCD risk factor identification. The younger
age groups and those with high risks are targeted through continuous health promotion
strategy and creating an environment that supports healthy living.

Diabetes Mellitus was chosen as the primary and the earliest target for NCD prevention and
control. The action plan for NCD prevention and control was mainly formulated at the
National Diabetes Programme held in Ipoh in January 2000.The main objectives were to
review the programme at all levels and to improve recording, monitoring and surveillance
activities in the country pertaining to Diabetes. However being cognizant that targeting single
diseases was inadequate to prevent and control NCD and that there was a need for a
comprehensive, integrated approach to target all the major common NCD risk factors, the
MOH with the help of the WHO organized ‘The Integrated Prevention and Control of
Diabetes and Cardiovascular Diseases’ in the year 2002 with the objective to develop
national policies, identify appropriate strategies and to formulate a plan of action for the
Integrated Prevention and Control of CVD and Diabetes.

230
Understanding that the most important person in the prevention and the control of the NCD is
the patient himself it is important to empower the community to change their behaviour. This
is however is easier said than done. But in spite of all the challenges that this strategy poses it
is also the most effective preventive programme. Hence a lot of the NCD control programmes
have this element.

Non-Communicable Disease Control Programme

The general objectives of the disease control programme of the ministry of health is to
prevent or delay the onset of cardiovascular diseases and diabetes, and their related
complications and to improve their management by providing multidisciplinary care for
chronic diseases. This strategy is developed to enhance the quality of life of the population,
leading to longer and more productive lives and reducing the mortality and morbidity rates
caused by non-communicable diseases and unhealthy lifestyle by building a healthy society
by increasing the knowledge and awareness among healthcare workers and the general public
regarding current issues and factors which cause diseases. NCDs and their determinants are
evaluated and their progression monitored. This objective is achieved by the collaboration of
the MOH with the various ministries, NGO’s and the communities.

The specific objectives of the programme (NSP-NCD) is to raise the priority accorded to
NCD in development work at global and national levels, and to integrate prevention and
control of such diseases into policies across all government departments and strengthen the
national policies and plans for the prevention and control of NCD. And also to implement
interventions to reduce the main shared modifiable risk factors for NCD like tobacco use,
unhealthy diet, physical inactivity and harmful use of alcohol and promote research for the
prevention and control of NCD. The other objectives are to support and assist the community
in obtaining health facilities by behavioral changes and to promote partnerships for the
prevention and control of NCD at the regional and global levels and monitor NCD and their
determinants, and evaluate the progress.

231
Rationale for a National Strategic Plan (NSP)

Despite the efforts of the government in taking appropriate steps in the prevention of Non
communicable diseases in the country as outlined by the World Health Organization (WHO),
there has been an alarming rise in the NCD. The main reason for the rise could be due to the
lack of inter-sectoral collaboration and the failure in policy and regulatory interventions. Due
to this the NCD-NSP was developed to operationalize existing knowledge and current
scientific evidence in reducing the burden of NCDs in Malaysia, while taking into account
the national, social, cultural and economic context of Malaysians. NSP-NCD is a strategic
plan to tackle the increasing prevalence of NCD and the risk factors more effectively and
efficiently by addressing different faults in the current NCD prevention and control
programmes and activities. It emphasizes on the involvement of a myriad of stakeholders
including different ministries, private hospitals and clinics, professional organizations and
NGO’s related to health.

There are seven strategies NSP-NCD proposal for the prevention and control of Non
communicable diseases and the risk factors associated with it.

The seven strategies of NSP-NCD are

1. Prevention and Promotion

2. Clinical Management

3. Increasing Patient Compliance

4. Action with NGOs, Professional Bodies & Other Stakeholders

5. Monitoring, Research and Surveillance

6. Capacity Building

7. Policy and Regulatory Interventions

232
Strategy 1: Prevention and promotion

All existing health promotion and prevention programmes are strengthened and expanded and
new strategies based on the requirements and deficits in the system are introduced. Among
the activities are increasing the awareness of overweight and obesity and other NCD risk
factors and encourage early and regular screening practices; inculcate healthy eating habits
and encourage physical activity. A tested and effective method which includes using media is
intensified and expanded e.g. using social networking sites like Facebook. Understanding that
schools are a ready source of impressionable audience, the ministry plans to increase and
promote physical exercise and educate students concerning unhealthy foods. Schools will
also be used as screening centres for NCD risk factors. Workplaces will be targeted for
promoting physical activity, educating the workforce on healthy, nutritious and hygienic
food. Workplace can also be centre for screening NCD factors. Similarly community based
programmes which include health education and health promotion is strengthened and
expanded with the emphasis on promoting physical activity, improving access to healthy food
and screening for NCD risk factors.

Strategy 2: Clinical Management

In order to improve and expand the health delivery system as part of the NCD-NSP
programme, all health facilities are equipped with appropriate clinical equipment’s for the
assessment and management NCDes and their risk factors according to the standard operating
procedures. All medical practitioners are either observed or their case notes are reviewed to
ensure that the CGP and the SOP are adhered to. This includes all screening programmes
related to NCD. All health care professionals are required to attend CPD’s as a process of
updating themselves in the art and skill of screening and managing NCD. Intervention
programmes are emphasised and rehabilitation programmes are strengthened and expanded.

233
Strategy 3: Increasing patient compliance

All forms of treatments irrespective of how expensive and extensive they may be will only
work if the patient is compliant. Empowerment is the key. Patients and their families are
given adequate information to enable them to play an important role in the management of
their illness. NCD resource centres are now a mandatory facility in all health centres. These
resource centres are well equipped and staffed by trained health care personnel’s.

Strategy 4: Action with NGO‘S, Professional Bodies and other Stakeholders.

Community based lifestyle interventions requires a multi-sectoral partnerships. Advocacy

campaigns are developed and implemented at national, state and district targeting community
leaders and other relevant persons. The activities may include health camps, seminars,
workshops, talks and other training programmes including promotion of healthy diets and
physical activity.

Strategy 5: monitoring, research and surveillance

Research is an important aspect of the strategy as it provides the empirical evidence of the
costs of NCD, cost effectiveness and benefits of the strategies. Research also provides
evidence of trends and risk factors related to NCD. In relation to NCD, surveillance provides
valuable information. Behavioural Surveillance Survey (BSS) on healthy eating habits,
physical activity and risk surveillance to identify NCD and its risk factors are important
programmes for monitoring and evaluation.

Strategy 6: Capacity Building

Understanding that the health care personnel including assistant medical assistants and nurses
play an important role in the management of NCD programmes, enhancing the skills,
knowledge and attitudes of all categories of health care staff is imperative. They are trained in
the following areas - Healthy eating, Staying active, Obesity, Smoking cessation and
screening of NCD risk factors (including CVD). Training is also provided to teachers and
members of the Parent Teacher Association on NCD risk factors especially obesity including
its prevention and management and the importance of healthy eating and physical activity.
The MOH produces the guidelines, manuals and training modules for these programmes.
Members of the community are also trained. Core group of trainers which may comprise of

234
NGO’s are trained for the implementation of community based programmes for NCD risk
factors management according to the guidelines, manuals and training modules produced by
the MOH. Having a healthy workforce is economically beneficial. Employers are also trained
to raise the awareness on prevention and control of NCD’s. Mass media plays an important
role in the dissemination of accurate and important health information to the public. Because
of these media workers particularly the copywriters and TV/radio hosts are trained to
promote health and counter misinformation.

Strategy 7: Policy and Regulatory Interventions

NCD prevention and control programmes are merged into related health and non-health
policy areas including urban development, poverty alleviation, etc. Economic policies
including those that can help reinforce lifestyle choices through pricing, taxation and
subsidies are implemented. There are several existing policies which are already in place
which are relevant to the NCD prevention and control. To be successful in achieving the
objectives of the programmes, an interagency collaboration is important. The ministry of
health collaborates with other ministries including ministry of education, youth and sports,
agriculture and agro based industries, information, communication, arts and tourism, trade
cooperatives and consumerism, housing and local governments, transport, women family and
social affairs, rural and regional development, public services department and the ministry of
human resources for the success of the NSP-NCD. Among the programmes include the
development of National physical activity policy with the ministry of youth and sports,
incorporation of nutrition and physical activity policy in the development plans of all
ministries and agencies, promote the availability of fresh fruits and vegetables and hold
regular fairs, ensure decrease content of salt and sugar in processed food and drink via
regulations, increase the availability of safe community facilities for physical activity and
exercise, expansion of an effective public transport system to reduce the use of private
transport in Malaysia and encourage physical activity and the expansion of the compulsory
regular NCD risk factor screening of all employees age 40 years and above.

235
Selected Specific Programmes

1. Diabetes

The prevalence of diabetes for all age groups worldwide is expected to increase from 2.8% in
the year 2000 to 4.4% by the year 2030. By the year 2030, it is projected that there will be
366 million cases of DM. There is an alarming increase in the prevalence of diabetes in
Malaysia. The National health morbidity survey reported an increase in the prevalence of DM
from 11.2 % in 2006 (NHMS 2006) to 15.2 % in 2011 (NHMS 2011). For the total diabetes
prevalent in the country likewise increments were seen 7 % to 7.2% amongst the known
diabetics and the percentage of unknown diabetics in the country nearly doubled from 4.5%
to 8.0%.

Prevalence of DM ≥18 years old by age groups

Disease Registry
On the 1st of January 2011, the Ministry of health started a web-based application to support
the implementation of the annual “Diabetes Clinical Audit” amongst Type 2 Diabetes patients
in MOH Health Clinics. The National Diabetic Registry (NDR) is essential for service
planning, performances and to monitor the disease trend. The socio-demographic data and the
outcome data of all diagnosed diabetes patients in Malaysia are used for annual Clinical
Audit.

236
Diabetes screening at the District Level
Diabetes screening programme at the district level is to detect pre-diabetes and diabetes in
specific high risk population and to ensure timely and appropriate management. High risk
group with symptoms suggestive of DM (tiredness, lethargy, polyuria, polydipsia,
polyphagia, weight loss, pruritus vulvae, balanitis), pregnant women with risk factors, women
with history of gestational diabetes, any persons who is age ≥30 years and children and
adolescents who are overweight (BMI >85th percentile for age and sex, or weight >120% of
ideal) and/or have any two risk factors.

With symptoms

Venous Plasma Glucose

Fasting Random

<7.0 ≥7.0 ≥11.1 <11.1

OGTT OGTT

Type 2 Diabetes Mellitus

Flowchart for screening a suspected diabetic patient at the district level in Klinik Kesihatan*
*All values are in m/mol/L. Capillary whole blood reading is 12% lower than venous plasma glucose.

For asymptomatic individuals, screening should be done to adults who are overweight or
obese (BMI ≥23 kg/m2 or waist circumference ≥80 cm for women and ≥90 cm for men), and
have one or more additional risk factors for diabetes:
• First-degree relative with diabetes
• History of cardiovascular disease (CVD)
• Hypertension (BP ≥140/90 mm Hg or on therapy for hypertension)
• Impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) on previous testing

237
• High density lipoprotein (HDL) cholesterol <0.9 mmol/L or triglycerides (TG) >2.8
mmol/L
• Physical inactivity
• Other clinical conditions associated with insulin resistance (e.g. severe obesity and
acanthosis
nigricans)
• Women who delivered a baby weighing >4 kg or were diagnosed with gestational diabetes
mellitus
(GDM)
• Women with polycystic ovarian syndrome

Flowchart for screening of asymptomatic diabetic patient at the district level in Klinik Kesihatan

238
Source: Clinical Practice Guidelines: Management of Type 2 Diabetes Mellitus (5 th Edition), 2015.

The Diabetic clinic in Klinik Kesihatan is manned by a medical officer along with a trained
team of health care personnel and operates daily. The clinic has a well-equipped laboratory
and library with information relating to DM for patients. After the patient is registered, a
complete clinical history is taken followed by an examination by the staff in charge. Except
patients with complications who are seen by the medical officer, all other patients are
managed by the assistant medical officer. Besides treatment, counselling is given relating to
the complications of diabetes and the progression of the disease. Cases are referred to the
medical officer if there is a case of uncontrolled diabetes after a maximum dosage of
medication after 3 visits, uncontrolled hypertension (>130/80) even after 3 visits, occurrence
of new complications, worsening complications and all newly diagnosed cases. Rehabilitation
services consisting of counselling and self-care skills are also available in the diabetic clinics.
Patients with persistent complications, worsening symptoms or side effects of the medication
are followed-up by a doctor and patient is referred to a specialist if complications proceed.

Work process Completed by

Registration OPD card (Buku daftar pesakit Diabetes team
luar)
Examination  Symptoms of diabetes Diabetes team
 Physical examination  Staff nurses in charge
 Complication of complication
 Patient with
complication, referred
to medical officer
 Patient without
complication, refer to
medical assistant

Distribution of cases  Treatments Medical officer or medical

 Follow up assistant
(complication, medical
side effects,
progression of
diabetes)
 Refer to MO if:
-Uncontrolled diabetes
with maximum dosage
after 3 visits
-Uncontrolled
hypertension >130/80
even after 3 visits
-New complication

239
 -Worsen complication
-New disease
 Rehabilitation
-Counselling and self-
care
 Refer to specialist
-Complications

Follow up  Side effects of Medical assistant/ staff nurses

medication
 Complications
 Worsening
complications
Diabetes services in Klinik Kesihatan without a Medical Officer

The resource centre/library in the Klinik Kesihatan is set up to empower patients to take
control of their health though health education. It is manned by a medical officer, assistant
medical officer and staff nurses. The activities provided in the resource centre include foot
assessment and foot care, health education pamphlets, individual counselling and group
education, usage of Glucometer at home and a diabetes Camp. Quality assurance program
relating to Diabetes management is conducted annually to identity areas of areas of potential
improvement.

Diabetic Care At Home

As part of the programme to empower patients to take ownership of their health, they are
given a glucometer and subsidized ‘glucostrips’. The patients are taught to correctly test their
blood for glucose, glucometer care, recording of results, adjust treatments and to identify
hypoglycaemia or hyperglycaemia. Upon visit to the clinic the patient‘s diary is reviewed and
the patient is asked concerning any difficulties in the use of the glucometer.

240
Special Programmes
A District Diabetic Committee is formed to discuss and develop strategies and methods to
improve the current, on-going programmes. Depending on the location and level of
activeness of these committees there may be more than one programme. Examples of
programes that were and are being conducted are…..

‘Saya Mahu Sihat 1Malaysia ’ (SMS)

People living in the community within the Klinik Kesihatan at risk of NCD such as
overweight/obesity, smoking, substance abuse mental health problem and family history of
NCD are identified and screened

‘Cergas Unggul Tampan Elegan ’ (CUTE)

Is a weight reduction programme among civil servant initiated in one of the
districts in Penang.

2. Cardiovascular Disease (CVD)

Cardiovascular diseases account for most NCD deaths (17 million people annually) and they
are also the number one cause of death globally. The INTERHEART study, which is a
standardized case control study which screened all patients admitted to the coronary care unit
for a first myocardial infarction in 262 centres in 52 countries found that 90-95% of the risks
attributable to the causation of heart attacks were potentially modifiable risk factors i.e.
smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, reduced daily
consumption of fruits and vegetables, regular alcohol intake, and irregular physical activity.

241
 74.1%
72.8%73.4%

68.7%

61%

51.6%

44%

35.8%

27.2%
22.2%

14.3%
11.8%
8.1%

18-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

Prevalence of hypertension by age group (NHMS 2011)

Over 80% of CVD deaths occur in low and middle-income countries but both men and
women are equally affected. It is estimated that by 2030, almost 23.6 million people will die
from CVDs, mainly from heart disease and stroke.

At the district level

Patients who attend the selected health clinics are screened for risk factors like smoking,
obesity, hypercholesterolemia, diabetes, and hypertension which are associated with
cardiovascular diseases for early intervention to reduce the morbidity and mortality rates. The
criteria for screening risk factors include ≥35 year old, inactive, overweight, history of
hypertension on previous pregnancy, gave birth to baby which more than 4kg, family history
of diabetes and hypertension and smokers. The CVD assessment includes a complete history
of patient which would include duration of symptoms, family, dietary and drugs history,

242
followed by a physical examination which would include general physical examination, BMI
calculation, two or more BP measurement, fundoscopy, pulse rate and rhythm, cardiac, chest,
abdominal and neurological examination and signs of endocrine disorder. Initial investigation
may include full blood count, urinalysis, albumin/creatinine ratio, renal function test, fasting
blood sugar, BUSE/Creatinine, lipid profile, ECG and Chest X-Ray. When any abnormal
finding is detected, the patient is referred to a Medical Officer for further investigation.

3. Mental Health
In a ministry of health report, the vision of mental health services is to create a
psychologically healthy and balanced society emphasizing on promotion of mental health and
the prevention of psychological stressors. Mental health Act 2001 and the mental health
regulations 2010 were developed to ensure a comprehensive care, treatment, control,
protection and rehabilitation of those with mental disorders. In Malaysia mental health care is
integrated in all primary care clinics. These clinics offer mental health promotion services.
The staffs are trained to detect, treat and follow up stable cases and defaulter tracing. There is
also an element of psychosocial rehabilitation and family intervention. The objective of the
mental health services is to improve knowledge and awareness regarding mental health and
encourage the community to participate in screening programs to determine their mental
health status and the associated risk factors and empower them to improve skills in the
management of stress and depression.

243
 2.5%
2.2%
1.9%
1.7%

1.1%
1%

16-24 25-34 35-44 45-54 55-64 65+

Prevalence of current depression by age group (2011)

The staffs in the health clinic are trained to promote mental health literacy and promote an
acceptance and to value cultural diversity. The preventive programmes include the
identification of the population at risk and to screen them. All uncertain diagnosis and
patients who are not responding to treatment in primary health clinics are referred to a
psychiatrist.

The common screening tool used in Klinik Kesihatan is the DASS21, which is a common
screening tool used to screen for stress, depression and anxiety. Mini Mental State
Examination is another common tool used to screen for cognitive impairment among the
elderly.

The Klinik Kesihatan also conducts health promotion activities like Anti-Stigma campaigns,
encourage mental screening test in Klinik Kesihatan, stress management program in school
and workplace. Short but precise information is also available in pamphlet forms which are
readily given out to raise awareness and educate the public. Psychosocial rehabilitation in
health centres includes training stable patients with skills which are required for the daily
activities. Program Minda Sihat is another programme which was started with the objective to
build a nation whose population are psychologically balanced and healthy. This programme

244
includes 40 screenings per month and the staffs are given courses to help recognize mental
illnesses early and to ensure the correct way of handling patient.

4. Smoking - Quit smoking clinic

Tobacco kills nearly six million people each year, of which more than 5 million are users and
ex-users and more than 600,000 non-smokers are exposed to second-hand smoke. It is
estimated that the annual death toll could rise to more than eight million by 2030. Nearly
80% of the world's one billion smokers live in low and middle-income countries.
Consumption of tobacco products is increasing globally, though it is decreasing in some high-
income and upper middle-income countries. It is estimated that by 2020 more than two-thirds
of the world’s smokers will be in Asia. Less than 11% of the world's population is protected
by comprehensive national smoke-free laws. Even non-smokers are not spared the risk of
cigarette smoke. In adults, second-hand smoke causes serious cardiovascular and respiratory
diseases, including coronary heart disease and lung cancer. Passive smokers are at 30%
higher risk of developing lung cancer and 25% higher risk of cardiovascular diseases. It is
reported that second-hand smoke causes more than 600,000 premature deaths per year.
Women passive smokers have higher infertility rates, low birth weight, still births and
premature deliveries. In infants, it causes sudden death. Children exposed to second hand
smoke are more susceptible to asthma, lung infections etc.

According to the Resource Centre of the Southeast Asia Tobacco Control Alliance
(SEATCA), the prevalence rate of smoking among men in Malaysia is just over 50%.
However, given that an increasing number of young people and even children, as young as
13, have grown addicted to smoking, it means that the proportion of smokers is far higher.
There has also been a sharp increase in female smokers in Malaysia, especially among young
women, girls and even expectant mothers. Overall, close to a third of the population of
Malaysia are current smokers and that number is growing.

It is estimated that national health care costs for tobacco-related diseases, such as chronic
obstructive pulmonary disease, ischemic heart disease and lung cancer, for a population with
smoking prevalence rate as Malaysia could amount to almost 2% of GDP, or nearly 20% of
the country’s total healthcare budget. And this figure is expected to rise further.

245
 Quit smoking services are available in certain selected Klinik Kesihatan to assist smokers to
quit smoking by using nicotine replacement therapy, motivational counselling and
behavioural modification. The objective of the Quit smoking clinic is to assist smokers to quit
smoking via effective techniques. The clinics provide knowledge on the harmful effects of
smoking and skills for smokers to quit smoking. Counselling on the benefits of quitting,
information on the harmful ingredients in the cigarettes, ways to overcome the urge to smoke
and to cope with the withdrawal symptoms are also dispensed. ‘Buku Panduan Berhenti
Merokok’ is also given to clients to help them understand the benefits of quit smoking.
Clients attending this clinic can be either walk-ins or referrals from doctor or school. The
addiction to the cigarettes is assessed using Fagerstrom scale. Measurement of carbon
monoxide content is done on smokers who intend to quit smoking. The treatment given
includes Nicorette, Champix, patch and Inhaler*. The patient is considered as successful in
quitting if he or she does not smoke consecutively for 6 months. The staffs also encourage
and motivate clients not to return to smoking once they have quit. Group discussion and
motivational talks are held with the patients who succeeded in quitting.

* Note: The treatment given depends on the avaibility of the product. In most Klinik
Kesihatan, the quit smoking approach focuses more on the health education and counselling.

There are several legislations relating to tobacco control in the national activity to curb
smoking
I. Control of Tobacco Products Regulation 1993
II. Tobacco Control Act
III. Ban on tobacco promotions
IV. Packaging and labelling
V. Sales to minors
VI. Tobacco smuggling
VII. Smoke free areas
VIII. Cigarette content and laboratory analysis

5. Nutrition and Physical Activity

The growth of the economy of the country coupled with free trade among nations has
propelled the food consumption of Malaysians. There has been a steady rise in the mean
calorie intake and in the intake of fast food. However there has not been a steady rise of the
activity level of the population. Studies have shown that 97% of population consumed rice

246
twice daily on an average of 2.5 plates/day although the habitual daily average intake of food
met the recommendations for cereals, fruits and vegetables; the consumption of meat was
higher than the recommended and milk consumption below the recommended levels. Due to
sedentary lifestyle and over intake of calories, the nation is facing a rapid increase in
prevalence overweight and obese population in the last few decades.

Prevalence of abdominal obesity by age group (2011)

72.4%
70.7%
68.8% 68.7% 67.6%
65.8% 66.8%
62.3%
59.3%
57.2%
55%

46.2%

30.4%

16-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

Prevalence of physical activity (2011)

247
This has probably led to an alarming increase diet related diseases such as type 2 DM,
Cardiovascular disease and Hypertension. In response to this epidemic, the Malaysian
government established the National Nutritional Policy (NNP) in the year 1995 followed by
the National Plan of action for Nutrition of Malaysia (2006-2015) was developed to achieve
and maintain the nutritional well-being of all Malaysians. The objective of this programme is
to improve good food intake and dietary practices of Malaysians. One of the recommended
strategies for the above plan is to enable every Malaysian to have access to information on
nutrition. Malaysian dietary guidelines is a compilation of the latest science based nutrition
and physical activity recommended by the Technical working group on Nutritional guidelines
under the supervision of National coordinating committee on Food and Nutrition (NCCFN).
The guidelines were implemented to encourage the people to consume fewer calories and be
more active and to make wiser food choices.

The objective of the nutritional service is to promote healthy eating and active lifestyle, and
creating awareness regarding diseases that are caused by improper diet, eating habits and
sedentary lifestyle among all age group to avoid morbidity associated with overweight and
obesity.

Clients may either walk in or can be referred by a doctor or referred from school. Counselling
is conducted by a nutritionist based on the food pyramid concept. The client is told about
calories, the meaning of Body Mass Index, waist to hip ratio and other tests related to obesity.
There are also weekly aerobic activity and other games for the staff and public in certain
Klinik Kesihatan gymnasiums.

248
Pyramid Level Type of food
One serving of milk and dairy products 1 slice of cheese
1 glass of low fat milk
2/3 cup of evaporated milk
4 dessert spoons (heaped) of powdered milk
1 cup of yoghurt
One serving of fish, poultry and meat 2/3 cup of anchovies (head removed)
2 pieces of lean beef (7.5am x 9cm x 0.5cm)
1 piece of chicken drumstick
1 cup of cockles
2 whole eggs
1 medium ikan kembung
1 medium ikan selar
1 piece of ikan tenggiri (14cm x 8cm x 1cm)
2 pieces of chicken liver
12 whole telur puyuh
2 medium squid
One serving of legumes 1 cup of chickpea and dhal
1 ½ cups of green/mung bean and canned baked beans
2 pieces of tempeh/tau-kua/ tau-hoo
1 ½ glasses of unsweetened soya bean milk
One serving of vegetables ½ cup of cooked dark green leafy vegetables with edible stem
½ cup of fruit vegetable, cooked
1 cup of raw ulam
One serving of fruit 1 hole apple, Chinese pear, mango, ciku
1 whole banana, berangan (medium size)
2 whole banana, emas
3 ulas durian
8 small grapes
½ whole guava/pear
1 whole mandarin orange (small to medium)
1 slice of papaya, pineapple, watermelon
4 small prunes
1 dessert spoon of raisins
One serving of cereals and cereal products and tubers 1 ½ cups of soaked bihun
6 pieces of biscuits, cream creakers
2 slices of white bread
2 slices of wholemeal bread
1 ½ cups of soaked laksa
1 cup of wet mee or kuey-teow
2 whole potato
2 pieces of putu mayam
2 senduk/ 1 cup of cooked white rice
2 cups of plain rice porridge
1 cup of sweet potato, yam, tapioca

249
6. Cancer
The Age–standardized Incidence Rate (ASR) for all cancers in Malaysia according to the
National Cancer Registry was 131.3/100,000 in the year 2006 (NHMS-2006). The top five
most common cancers in Malaysia are breast, colorectal, lung, cervix and nasopharynx. The
ASR for males was 128.6/100,000 and for females was 135.7/100,000. Cancer prevalence is
higher among the Chinese as compared to the other ethnicities in Peninsular Malaysia. The
most frequent cancer among the paediatric age group (0-14yrs) was Leukemia whereas
among young male adults (15-49 yrs) nasopharynx, colorectal, lung, brain and leukemia and
among females, breast, cervix, thyroid, ovary and colorectal cancers. In the older male age
group (50 years and above) cancers of the colorectal, lung, nasopharynx, prostate and liver
were the most common and among older female age group breast, colorectal, cervix, lung and
ovarian cancers occurred commonly.

The objectives of the services relating to cancer are to provide information and create
awareness to the community regarding different types of cancer and to promote screening for
cancer. There are several approaches taken by the ministry of health to combat cancer which
includes public education, Pap smear screening, HPV vaccination, breast self-examination
and mammogram, cancer education in school and colorectal screening. In Klinik Kesihatan,
the screening of cervical cancer using Pap smear test and breast cancer using mammogram is
recommended once in every three years for women aged 40 years below in the general. For
women aged 40 years and above and those with high risk factors, annual screening is needed.
For colorectal screening in Klinik Kesihatan, patient aged 50 years and above without any
symptoms will be screened randomly using Fecal occult blood test (FOBT). If the test is
positive, the patient will be referred to the Surgical Outpatient Department (SOPD) for
colonoscopy. If the result is positive, they will be treated accordingly and if the result is
negative, they will be followed-up in Klinik Kesihatan.

250
7. Asthma
Although Asthma is categorised as an environmental disease, it is managed in Klinik
Kesihatan. Asthma is a lung disease that has the following characteristics: airway obstruction
that is reversible (but not completely so in some patients) either spontaneously or with
treatment; airway inflammation; and increase airway responsiveness to a variety of stimuli.
The strongest risk factors for developing asthma are a combination of genetic predisposition
with environmental exposure to inhaled substances and particles that may provoke allergic
reactions or irritate the airways. Indoor allergens (for example, house dust mites in bedding,
carpets and stuffed furniture, pollution and pet dander), outdoor allergens (such as pollens
and moulds), tobacco smoke, chemical irritants in the workplace, air pollution are common
irritants. Other factors may include cold air, extreme emotional arousal such as anger or fear,
physical exercise and certain medications e.g. beta blockers, aspirin.

235 million people currently suffer from asthma and half of them live in Asia. It is the most
common chronic illness among children. Most asthma-related deaths occur in low and lower-
middle income countries where asthma is under-diagnosed and under-treated and inadequate
supervision leading to mortality related to asthma. It creates substantial burden to individuals
and families resulting in not only health burden but economic burden as well. Asthma
restricts sports and recreation by 53%, normal physical activity by 45%, choice of job or
career by 38%, child play/lifestyle by 38% and household chores by 33%. With appropriate
treatment and care most of the morbidity and mortality can be prevented. Although asthma
cannot be cured, with appropriate management asthma can be controlled to enable victims to
enjoy a good quality of life.

The prevalence of asthma in Malaysia among primary school children was reported at 13.8%,
children aged 13-14 years 9.6%, adult (self-reported) 4.1%. The prevalence was higher in
rural (4.5%) than in urban areas (4.0%) and the prevalence is also higher in those with lower
educational status (5.6%) and lower income (4.7%).

WHO has suggested that the surveillance of asthma should be done to map the magnitude of
the illness, analyse its determinants and monitor trends, with emphasis on poor and
disadvantaged populations. WHO recommends primary prevention to reduce the level of
exposure to common risk factors, particularly tobacco smoke, frequent lower respiratory
infections during childhood, and air pollution (indoor, outdoor, and occupational exposure)

251
and to identify cost-effective interventions, upgrading standards and accessibility of care at
different levels of the health care system.

In the Klinik Kesihatan a record book (‘buku rekod harian gejala asma’) is provided for every
asthma patient to fill in daily for the health personnel to measure the efficacy of the
treatment. This book also has information regarding asthma. The patient to records four main
symptoms daily i.e. sleep disturbance, cough, wheezing and shortness of breath on exertion.
The patient is required to report once in 3 months or if there is an exacerbation of any
symptoms to the asthma clinic.

Other Programs by MOH

Program Komuniti Sihat Perkasa Negara (KOSPEN)

Program Komuniti Sihat Perkasa Negara (KOSPEN) is one of the initiatives by the Ministry
of Health Malaysia in the effort of tackling non-communicable diseases and improve the
quality of health of Malaysians through strengthening and expansion of community
participation in the health programs. The program involves the collaboration between staffs
of MOH, KEMAS (Kemajuan Masyarakat) and volunteers from the community. The
program aimed at behavioral change by empowering the community. The strategies
employed in KOSPEN include increasing awareness & knowledge, health-promoting living
environment and translation of knowledge into sustainable actions. Health promotion and
health education are approaches used under KOSPEN. Various topics are covered under
KOSPEN among which includes active living style, healthy eating and weight management,
smoke-free, screening and early detection of NCD. Self-monitoring of BMI, blood pressure
and blood sugar are some of the examples of program carried under KOSPEN.

252
 CHAPTER 10: FOOD SAFETY AND QUALITY CONTROL

INTRODUCTION:
Food is composite mixture of substances which when consumed performed certain functions
in the body. The main functions of food are: to yielding energy; for building and maintaining
the body and Protecting the body and regulating the tissue functions. Whereas Nutrition is the
process in living organisms utilize food for maintenance of life, growth, the normal
functioning of tissues and organs, and the production of energy. Nutrients are the organic and
inorganic complexes contained in food. About 50 nutrients are supplied in food. Most of the
natural food contains more than one nutrient. Macronutrients that needs in large amounts -e.g.
Proteins, fats and carbohydrates and Micronutrients in very small amounts microgram/
milligram] - e.g. Vitamins and Minerals. Diet on the other hand is prescribed food. It is the
total solid, semi solid or liquid foods consumed by an individual or by a population group,
either on an average basis or during a specified period.

CLASSIFICATION OF FOODS:

The usual basis of classification of food is its origin, chemical composition, Predominant
Functions and nutritive values.

1. Food according to its origin-

(a). Vegetables e.g. Paddy, fruits.
(b). Animal e.g. Meat, fish, egg.

2. Food according to its Chemical composition-

(a) Proteins (b) Fats (c) Carbohydrate (d) Vitamins (e) Minerals

3. Food according to predominant functions

(a). Body building food e.g. Meat fish milk
(b). Energy giving food e.g. cereals, sugar, fat oils etc.
(c). Protective foods-vegetables, fruits, milks

253
4. Food according to Nutritive value; e.g. Cereals, Pulses, vegetables, Nut and oils, Animal
foods.

FOOD SAFETY / FOOD HYGIENE:

WHO has defined food safety / food hygiene as “All the conditions and measure that are
necessary during the production, processing, storage, distribution and preparation of food to
ensure that it is safe, sound, wholesome and fit for human consumption”. The aims of food
hygiene is to (a) prevent food poising and (b) other food borne illness
Diseases which may be infectious or toxic in nature which are caused by agents that enter the
body through ingested food are called food borne illnesses. Food borne illnesses are a serious
problem among developing countries especially those with poor socio-economic status. The
WHO estimates that about 251 people die of water and food borne diarrhoeal diseases every
hour. Food borne hazards are defined as “a biological, chemical or physical agent in or
condition of food with the potential to cause an adverse health effect”. These hazards include
 Biological such as infectious bacteria, toxin producing organisms, moulds, parasites
and viruses. The common enteropathogens are Salmonella typhi, Vibrio cholera, E.
coli, Vibrio vulnificus and Listeria monocytogenes. Also cause of concern are the
Salmonella serotype Typhimuriums and the parasite Cyclospora cayetanensis.
 Chemical hazards such as natural toxins, food additives, pesticide residues, veterinary
drug residues, environmental contaminants and allergens and
 Physical hazards such as metal, machine fillings, glass, jewellery, stone and bone
chips.

Cholera, typhoid fever, Hepatitis A, food borne illnesses and dysentery are the five main
diseases monitored by the ministry of health Malaysia. The incidence of cholera is higher in
Sabah whereas typhoid is higher in Kelantan.

254
Year / 1998 1999 2000 2001 2002 2003 2004 2005 2006

Disease

Cholera 1,304 536 124 557 365 135 89 386 237

Dysentery 246 429 447 348 292 310 356 141 105

Food 6,976 8,640 8,129 7,137 7,023 6,624 5,957 4,641 6,938
poisoning

Typhoid 782 811 765 695 853 785 484 1,072 204

Hepatatis A 240 319 497 453 295 222 107 44 64

Table showing the incidence of food and water borne diseases in Malaysia for 1998-2006.Source ministry of
health Malaysia

FOOD BORNE DISEASES AND ITS CLASSIFICATION:

A Food borne is usually either infectious or toxic in nature, caused by agents that enter the
body through the ingestion of food”. It may be
A. Food intoxications-
1. Due to naturally occurring toxins in some foods, e.g. Lathyrism (beta oxalyl
amino- alanine); Endemic ascitis (pyrrolizidine alkaloids).
2. Toxin produced by bacteria, e.g. Bolulism, staphylococcus poisoning.
3. Toxin produced by some fungi- e.g. Aflatoxin, Ergot, Fusarium toxins.
4. Food borne chemical poisoning- e.g. Heavy metals (Mercury in fish, lead in
tinned food); pesticides-DDT; chemicals from package materials.

B. Food borne infections

1. Bacterial diseases- typhoid, salmonellosis, food poisoning etc.
2. Viral infection- hepatitis, gastro-enteritis
3. Parasites- Taeniasis, Hydatidosis, Amoebiasis, Ascariasis.

255
 CHAPTER 10: FOOD SAFETY AND QUALITY CONTROL IN MALAYSIA

INTRODUCTION:
Food is composite mixture of substances which when consumed performed certain functions
in the body. The main functions of food are: to yielding energy; for building and maintaining
the body and Protecting the body and regulating the tissue functions. Whereas Nutrition is the
process in living organisms utilize food for maintenance of life, growth, the normal
functioning of tissues and organs, and the production of energy. Nutrients are the organic and
inorganic complexes contained in food. About 50 nutrients are supplied in food. Most of the
natural food contains more than one nutrient. Macronutrients that needs in large amounts -e.g.
Proteins, fats and carbohydrates and Micronutrients in very small amounts microgram/
milligram, e.g. Vitamins and Minerals. Diet on the other hand is prescribed food. It is the
total solid, semi solid or liquid foods consumed by an individual or by a population group,
either on an average basis or during a specified period.

CLASSIFICATION OF FOODS:

The usual basis of classification of food is its origin, chemical composition, Predominant
Functions and nutritive values.

1. Food according to its origin-

(a). Vegetables e.g. Paddy, fruits.
(b). Animal e.g. Meat, fish, egg.

2. Food according to its Chemical composition-

(a) Proteins (b) Fats (c) Carbohydrate (d) Vitamins (e) Minerals

3. Food according to predominant functions

(a). Body building food e.g. Meat fish milk
(b). Energy giving food e.g. cereals, sugar, fat oils etc.
(c). Protective foods-vegetables, fruits, milks

256
4. Food according to Nutritive value; e.g. Cereals, Pulses, vegetables, Nut and oils, Animal
foods.

FOOD SAFETY / FOOD HYGIENE:

WHO has defined food safety / food hygiene as “All the conditions and measure that are
necessary during the production, processing, storage, distribution and preparation of food to
ensure that it is safe, sound, wholesome and fit for human consumption”. The aims of food
hygiene is to (a) prevent food poising and (b) other food borne illness
Diseases which may be infectious or toxic in nature which are caused by agents that enter the
body through ingested food are called food borne illnesses. Food borne illnesses are a serious
problem among developing countries especially those with poor socio-economic status. The
WHO estimates that about 251 people die of water and food borne diarrhoeal diseases every
hour. Food borne hazards are defined as “a biological, chemical or physical agent in or
condition of food with the potential to cause an adverse health effect”. These hazards include
 Biological such as infectious bacteria, toxin producing organisms, moulds, parasites
and viruses. The common enteropathogens are Salmonella typhi, Vibrio cholera, E.
coli, Vibrio vulnificus and Listeria monocytogenes. Also cause of concern are the
Salmonella serotype Typhimuriums and the parasite Cyclospora cayetanensis.
 Chemical hazards such as natural toxins, food additives, pesticide residues, veterinary
drug residues, environmental contaminants and allergens and
 Physical hazards such as metal, machine fillings, glass, jewellery, stone and bone
chips.

Cholera, typhoid fever, Hepatitis A, food borne illnesses and dysentery are the five main
diseases monitored by the ministry of health Malaysia. The incidence of cholera is higher in
Sabah whereas typhoid is higher in Kelantan.

257
Year / 1998 1999 2000 2001 2002 2003 2004 2005 2006

Disease

Cholera 1,304 536 124 557 365 135 89 386 237

Dysentery 246 429 447 348 292 310 356 141 105

Food 6,976 8,640 8,129 7,137 7,023 6,624 5,957 4,641 6,938
poisoning

Typhoid 782 811 765 695 853 785 484 1,072 204

Hepatatis A 240 319 497 453 295 222 107 44 64

Table showing the incidence of food and water borne diseases in Malaysia for 1998-2006.Source ministry of
health Malaysia

FOOD BORNE DISEASES AND ITS CLASSIFICATION:

A Food borne is usually either infectious or toxic in nature, caused by agents that enter the
body through the ingestion of food”. It may be
A. Food intoxications-
1. Due to naturally occurring toxins in some foods, e.g. Lathyrism (beta oxalyl
amino- alanine); Endemic ascitis (pyrrolizidine alkaloids).
2. Toxin produced by bacteria, e.g. Bolulism, staphylococcus poisoning.
3. Toxin produced by some fungi- e.g. Aflatoxin, Ergot, Fusarium toxins.
4. Food borne chemical poisoning- e.g. Heavy metals (Mercury in fish, lead in
tinned food); pesticides-DDT; chemicals from package materials.

B. Food borne infections

1. Bacterial diseases- typhoid, salmonellosis, food poisoning etc.
2. Viral infection- hepatitis, gastro-enteritis
3. Parasites- Taeniasis, Hydatidosis, Amoebiasis, Ascariasis.

258
FOOD SAFETY AND QUALITY CONTROL IN MALAYSIA:

Food Safety and Quality Control Division is a division in the Ministry of health,
Malaysia.The responsibilities of the food safety and quality control division in Ministry of
Health Malaysia include food sampling, inspection of food premises, food export control,
food import control, food safety certificationsystem e.g. Hazard Analysis Critical Control
Point (HACCP), Good Manufacturing Practice (GMP), ‘Makanan Selamat Tanggungjwab
Industri’ (MeSTI) and ‘Bersih, Sihat dan Selamat’ (BeSS)., Licensing of Mineral Water,
Bottle Drinking Water and Ice and enforcement and legal action. At the district level, the
head of the unit is the Medical officer of health and the food technologist and the senior
environmental and health officer who supervise all the food safety and quality control
activities at the district level and they will report to the medical officer of health.
The main objective of the division of food safety and quality control is to protect the general
public from health hazards related to production, sales and storage of food. Its specific
objectives include ensuring

 the preparation, sales and storage of all food materials are clean and safe for
consumption
 all foods which are sold are labelled correctly with sufficient information concerning
the ingredients and contents
 all sold food are free from contamination and unnecessary additives and comply with
requirements of the Food Act 1983 and Food Regulations 1985
 all exported food fulfils the necessary requirements of the importing countries
 all imported food comply with requirements of Food Act 1983 and Food Regulations
1985 are
 the general public have sufficient information on the aspects of food safety.

Responsibilities
The responsibilities of the food safety and quality control unit at the district levels includes
carrying out food sampling for chemical and micro analysis to ensure that the food available
in the market and factory is compliant with the existing food standards; inspection of food
premises to ensure that the standard of hygiene and the food handler behaviour are at optimal
levels to ensure that the food produced is safe and free from contamination; checking the
health status, TY2 vaccination and also a training obtained from MOH accredited food
handlers training school among the food handlers; issuance of health certificate for export

259
purpose and prepare investigation files for court action against food premise owners found to
have breached the Food Act 1983 and Food Regulations 1985; and participating in the
courses, exhibitions and dialogue that are related to the goals and objectives of the Food
Quality Control Unit. Whereas the responsibilities of the officer at the entry points include:
inspections of food consignment and also carrying out food sampling for chemical and micro
analysis to ensure that the imported food is compliant with the existing food standards.

Food Act 1983, Food Regulation 1985 and Food Hygiene 2009
The principal food law in Malaysia is the Food Act which was gazetted on March 10th 1983
and the food regulation was gazette on 26th September 1985 and both were enforced together
on the 1st of October 1985. Both laws were developed and amended by the Food Safety and
Quality Control Division. The Food Act 2003 is an Act to protect the public against health
hazards and fraud in the preparation, sale and use of food, and for matters incidental thereto
or connected therewith. These laws help to ensure safe good and beverage consumption in
food outlets and premises. The Food Hygiene Regulations 2009 provides an infrastructure to
control the hygiene and safety of food sold in the country to protect public health.

Medical officer of Health

Food Technology Officer

Senior Environmental Health Officer

Food Inspection of Food export Enforcement

Sampling food premises and Legal

Organization chart of Food Safety and Quality Control

A. Food Sampling Unit & B. Premise/School Investigation Unit

Depending on the type of test required, the sample is usually tested for chemicals (e.g. boric
acid), microbiological (e.g. E.Coli, aflatoxin) and physical (e.g. glass, wood) impurities.
Three samples of the same specimen is required for chemical analysis- one is sent to an
accredited Food Quality Control Laboratory, second sample is kept in the District Health

260
Office and the third sample is kept by the premise owner/manufacturer. Each sample must
have a minimum weight of 250gm. It must be placed in a sterile package and sealed using the
Ministry of Health seal. For Microbiological or Physical Analysis, only one sample specimen
is required. Food sampling is also conducted in factories for Health Certificate application.

Premise/School Investigation Unit is responsible for ensuring the level of cleanliness of food
premises by means of encouragement and by enforcement of the law. Similar to the Food
Sampling unit, the activities are carried out either formally i.e. after an outbreak/complaint or
informally i.e. randomly. Assistant Environmental and Health Officer @ Health Inspectors
can legally close the premises using the Food Act 1983, Food Regulations 1985 and Control
of Communicable Disease Act 1988.

Premise inspection is carried by the Assistant Environmental and Health Officer based on the
following criteria
 In response to a complaint about a food premise
 If a case of food poisoning is notified from the hospital after eating in a food premise
 During routine yearly check-up of the food premise(to issue cleanliness grade)
 If need to take food samples for lab investigation

Premise Inspection can be conducted in food stalls, factories, tourist areas and anyplace that
sells/processes food for commercial purposes. When the Assistant Environmental and Health
Officerinspectsa premise for inspection to grade the premise, the minimum score that is
required is 70%. The scoring system is bases on the following

Total mark = 100 − (total demerit marks obtained by the premise / total mark of demerit in
the form)

Premises that obtain a score of less than 65 % will be closed for a maximum of 14 days, after
which it will be re-inspected. The owner/s of the food premise will be told for the reason of
closure and advised on how to improve. On re-inspection, the premise will have to score a
passing mark of 70% in order to reopen for business.

The criteria which is required for an operator to pass the inspection include

261
 Raw food and prepared food must be kept separate = 9%
 Food handlers must be properly vaccinated against Typhoid Fever = 8% (Valid for 3
years)
 Washing of plates, utensils etc. is done above the floor = 3%
 Waste bins are covered = 6%
 Food hygiene training valid for life (unless the food handler was involved in food
poisoning, he/she needs to renew the certificate)

262
 BORANG KKM-PPKM-2/09
BORANG PENILAIAN PREMIS MAKANAN BERASASKAN RISIKO
JENIS
BISNE JENIS
PEJABAT KESIHATAN DAERAH S PEMERIKSAAN
UNIT KESELAMATAN DAN KUALITI MAKANAN Kilang Rutin
Katerin
g Susulan
Premis
jual Aduan
Petunjuk: 0 - Memuaskan, Markah demerit - Tidak memuaskan, N/A - hazad tidak
RTE
berkaitan dengan perniagaan makanan ini.
Kender Lain-Lain
aan (nyatakan)
1 - Pemeriksaan, 2 - lawatan Jenis Premis : ……………………………………………….
susulan (Contoh : Gerai/Penjaja/Van dll)

No.IC/PASSP Nama
NAMA PEMILIK : ORT Syarikat/Premis:
No. Pendaftaran
ALAMAT PREMIS: Perniagaan:
No. Pendaftaran
KKM :
POSKOD Bil Pekerja:

Waktu Perniagaan
No. Telefon: No.Fax: tempoh/Jam:
Tarikh Masa
Masa Tarikh
Pemeriksaan Pemeriksaa Markah
Pemeriksaan(1) Pemeriksaan (2) Pemeriksaa
(1) n(2)
n
Terdahulu

MARKAH B MARKAH
BIL PERKARA PEMERI I PERKARA PEMERIKSAA
KSAAN L N
Demerit 1 2 Demerit 1 2
2 6.KEMUDAHAN PEPARITAN &
3
1.KAWALAN PROSES 5 PERPAIPAN
1 Titik Kawalan Kritikal (atau peringkat proses 15 1 Penyediaan kemudahan/sistem pembuangan
terpenting) 8 air limbah yang efektif 1
Kawalan e.g masakan 70°C atau lebih, makanan 19 Tiada persilangan line dan aliran berbalik 1
berisiko 2 Disediakan/dipasang dan berfungsi dengan 1
tinggi disimpan dibawah 4°C atau lebih 60°C, peti 0 baik
sejuk beku dikawal dibawah 0°C, pH pada atau
dibawah 4.6, 7.KEMUDAHAN SANITASI 6
rapid-cooling techniques, dll.
2 Spesifikasi pembekal & pemeriksaan fizikal sebelum 5 2 Tandas yang mencukupi dan berkeadaan
digunakan 1 baik/ berfungsi (atau akses kepada tandas 1
am/awam*)
3 Pencemaran silang dikawal menerusi saiz, 5 2 Kemudahan persalinan & mandi yang 2
rekabentuk 2 mencukupi*
& peralatan sesuai
2 Kemudahan mencuci tangan: Mencukupi dan 3
2.BANGUNAN 7 3 sesuai pengering tangan atau tuala pakai
buang, sabun cecair
4 Terletak jauh dari punca pencemaran 1 8.PENGURUSAN SAMPAH / BAHAN SISA 2
5 Lantai yang sesuai dan berkeadaan baik* 2 2 Bekas atau tong sampah yang bersih dan 1
6 Dinding & Siling yang sesuai dan berkeadaan baik* 4 mencukupi dan mempunyai jadual
2 pembuangan
7 Pencahayaan yang mencukupi 25 Penyelenggaraan tempat pengumpulan 1
sampah yang bersih dan mencukupi di luar
1 premis
8 Pengudaraan yang mencukupi 1 9.KAWALAN MAKHLUK PEROSAK 3

2 Terdapat kawalan yang efektif dan

13 3
3.PENGENDALI MAKANAN 6 mencukupi
9 Pemeriksaan kesihatan pengendali makanan 2 10.PEMBERSIHAN & 2

263
 PENYELENGGARAAN PREMIS
1 Amalan kebersihan pengendali makanan (termasuk 4 27 Pembersihan & penyelenggaraan yang 1
0 menghalang pekerja yang sakit bekerja dll) berjadual (termasuk pembuangan peralatan
yang tidak
1 Pakaian perlindungan diri pengendali makanan 3 digunakan)
1
1 Latihan (termasuk rekod) 4 28 Penyimpanan bahan pencuci yang 1
2 berasingan dengan makanan

4. PERALATAN & PERKAKAS MAKANAN 9 11.PENGANGKUTAN DAN 1

DAN KAWASAN PENYEDIAAN MAKANAN PENGHANTARAN
1 Permukaan menyentuh makanan (termasuk 3 29 Pembersihan mencukupi, kawalan suhu dan 1
3 peralatan): Permukaan direka & dibina dengan baik, penyelenggaraan
diselenggara & berfungsi, senang dicuci dan
berkedaan bersih
1 Permukaan yang tidak menyentuh makanan (Non- 1 12.OPERASI-OPERASI LAIN 1
4 food contact surfaces)
Rekabentuk dan binaan permukaan sesuai, 30 Dokumentasi /Notis (Contoh : Notis cuci
diselenggara tangan, dilarang membawa masuk binatang
dengan baik, mudah dicuci dan sentiasa bersih dll.)

1 Fasiliti dan kaedah pembersihan peralatan : 3 13.PROSES LAIN YANG ADA KAITAN 10
5 Rekabentuk & binaan yang sesuai dan digunakan DENGAN RISIKO TERHADAP KESIHATAN
serta dijaga / diselenggara dengan baik AWAM
1 Penyimpanan: Bersih, dilindungi, ada sistem FIFO 2 31 Ditolak dengan tambahan 10 markah jika isu 10
6 dan sesuai dengan jenis makanan bukan proses boleh menyebabkan risiko yang
serius
5.BEKALAN AIR (WATER SUPPLY) 5 14.UNTUK KILANG SAHAJA 35
1 Punca bekalan air: selamat, bersih & mencukupi# 5 32 Pengujudan Program Jaminan Keselamatan 30
7 Ais diperbuat daripada punca air selamat# Makanan
33 Kebolehkesanan (Traceability) 5

* TIDAK TERMASUK PENJAJA (HAWKERS)

(Jum Skor: Kilang = 122, Hawkers = 80,
Restoran/Kedai/Gerai dll = 87)
# Premis boleh ditutup jika tiada bekalan air selamat dan ais digunakan bukan dari punca air
selamat

JUMLAH MARKAH PENILAIAN TAHAP KEBERSIHAN:

Pemeriksaan Pertama Pemeriksaan Susulan

100
100 tolak
tolak
Skor Tahap Kebersihan Skor demerit Tahap kebersihan
demerit
Disah oleh
Diperiksa Oleh: Penyelia:

(Tandatangan) (Tanda tangan)

Nama Pegawai
Yang Diberi Nama Penyelia:
Berkuasa:

In cases of outbreak of food poisoning, a medical officer receiving a case of food poisoning
outbreak will be required to notify the Ministry of Health within 24 hours of the outbreak.
Both the Food Sampling and Premise Inspection team will carry out a thorough investigation
(sampling and premise inspection) on the premise.Even if the premise hasa high score
(≥70%) during the inspection, it is mandatory that the food premisebe closed during the food
poisoning outbreak investigation. All cases will be interviewed to narrow down the possible

264
causative food. A sample group of people eating at that particular place at the same time will
also be interviewed to form a control group. If sample of the food is available, it will be taken
as a specimen to the Food Quality Control Laboratory for analysis.

The specimen may be a

 formal sample - if the suspected causal food is still available or entire raw and/or
cooked food product will be sampled.
 swab - from utensils or other surfaces in contact with food
A preliminary report must be completed within 24hours prior to a full report that will be
submitted to the district health office once the lab analysis report is availed.

265
 Notification

Informs the lab

At the Inspection site

Inspection of Food Sampling

premises

Send sample to the

laboratory
Closure of premises *receipt acknowledgments

Second inspection
Entry record in the book
after registering sample
Satisfactory Not satisfactory

To give an Continue closed Lab result

authorization to notice
operate the premises

Inform the result to the

CDC Unit
Third
inspection
Satisfy

Filing

Flow chart for the investigation of food poisoning

266
Factory Inspection

Factory Inspection is part of the Food Quality Control Program. Factories producing or
packing food related products are regularly inspected by the Food Safety and Quality unit of
the District Health Office to evaluate the overall general cleanliness, food handling methods
and safety in the factory. As a routine a factory is inspected once a year. In addition, random
visits and sampling are done and factories are also inspected when a complaint is received or
when the manufacturer wishes to submit anapplication for Health Certificate. This is only
applicable for food premises which do not have Ministry of Health Food Safety certification.

The objective of the factory inspection is to

 evaluate the cleanliness and the safety in storage, cooking and packaging of food in
the factory
 ensure that the products of the food factory comply with the Food Act 1983 and Food
Regulations 1985 and
 protect the general public from health hazards related to food.

The inspectorate division uses a demerit system to evaluate a factory. Each factory is given a
merit point of 100 and the total demerits earned by the factory inspected will be calculated by
the score deducted from the total score of 100. A factory that obtains a score of less than 70
will be closed for 14 days and the factory management will be required to follow instructions
and the advice given by the officers to amend the weaknesses identified. On re-evaluation if
the score is above 70, the factory will then be allowed to commence operations.

The inspection of the factory includes the following aspects

 Food:all raw materials must be fresh, safe and stored in a clean environment, above
apallet. All pallets, especially wooden pallets, must remain dry and pest/insect-free.
To ensure that the shacks or containers containing raw materials do not directly touch
the wall, there should be at least a space wide enough for a person to fit in between
the containers and the wall.

 Protection/Storage/Management of food: all raw materials must be stored in a

covered shack/container and transported in a safe and hygienic way. All frozen food
must be stored in freezers set at temperature below 0°C and when transported the
temperature of refrigerators has to be set between 0 to 4°C. All raw and cooked food

267
 must be stored separately. Toxic materials such as detergent must be stored away
from food handling/storage areas. Processing of raw to cooked material to packaging
of all food must be handled in a safe and hygienic manner.

 Food Handlers:all the workers handling food must be given an anti-typhoid vaccine
injection every 3 years and they must undergo Food Handling Course for which they
are charged a nominal fee. All food handlers are required to maintain good self-
hygiene and remain free from infection. They must not smoke in the premise and
must also be in appropriate attire (apron, cap, shoes/boots and gloves).

 Equipment’s and tools on premise:all surfaces in contact with food must be cleaned
regularly and ideally made of stainless steel. It is mandatory all the cloths used in the
factory should be colour coded according to different types of usage for easy
identification.The oil used for preparing food products must not be reused.

 Water supply:water source and supply must be clean. Water obtained from tanks
pipes located in the toilet is not allowed.

 Sewage and Pipe:depending on the type of factory, before disposal the water must be
filtered and treated with appropriate chemicals and there shouldn’t be any backflow in
the piping system.

 Toilet:the toilet must be clean and not used for storage of any raw material or finished
product.

 Waste Disposal: wastes must be disposed regularly in rubbish bins lined with plastic
bags and these rubbish bins must be covered all the time.

 Pest, rodents and animal control: there must be no pets in the factory premises and
there should be a scheduled inspection from pest control companies.

 Structure of building:the building must be safe, with ample space for pathway, well
lighted and ventilated and have fire exit pathways for emergencies.

 Cleanliness of premise:there must be a daily cleaning schedule.

268
  Others:all licenses including the operating license must be displayed and enough fire
extinguishers in the premise.

The inspectorate team is also responsible for the control of imported or local food safety and
quality. They obtain samples of products for chemical, microbiological and physical analysis
and the control of food labelling. The Food technologist at the district level will conduct a
food safety audit and also adviceconcerning food quality control to manufacturers.

Frequent visit by Health Inspector to ensure the closed premises are not operating

Equipment checklist

Observe (No action taken) Refuse to follow the rules:

Obtain prove to get court’s action.
*Pictures (with date and time)
* Receipts (if necessary)

Make a police report immediately

Report to the district health officer about action

Complaint in the court

Open files of prosecution case

Process of investigation by health inspector if the premise owner does not comply with rules as outlined by the
food safety and quality control unit

As shown in the figure above, if a premise is closed for the first time due to the
noncompliance of the premise owner in accordance with the rules of the food safety and
quality control unit then the Assistant Environmental and Health Officer will revisit the
premise after one week to recheck the premise but if upon rechecking, the premise is found to
be operating within the period ordered for closure the Assistant Environmental and Health
Officer can lodge a police report and inform the Medical officer of health about the situation.

269
If a complainant lodges a complaint about a food premise to the food safety and quality
unit,an investigation is carried out by the Assistant Environmental and Health Officer.If the
complaint concerns the food served at the food premise then the premise inspection is
conducted and if found satisfactory (score above 50%) no action is taken and if found
unsatisfactory then the premise is closed and the confiscated materials sent for sampling. For
the case of school canteen the rating must be above 70%. The case is reported to the district
health office and the complainant is informed about the action/s taken. All the actions taken
are recorded and filed.

270
 Complainant makes a complaint

Indicate the details of the complaint

Not related to food Related to food

Inform other related Set a date and do

department
investigations

Not satisfactory Satisfactory

Action: Report
*Closing
*Confiscation
*Sampling
*Court

Report to DHO

Inform the complainant regarding

the actionthat has been taken.

Recorded in the file

Flowchart showing the investigation of complaints due to food premises

271
 B. Food Export Unit

Authorities in certain countries require a health certificate of the products imported into their
countries. The food export unit of the food safety and quality division is responsible for
ensuring that food items which will be used in local and overseas markets are safe and in
good quality and the exported food products meet the standards set by the regulations of the
importing country and subsequently protect the reputation of the Malaysian food industry.

The applicant's company which requires a health certificate must be a registered company.
Applications must be submitted before the product is exported and a detailed description of
the products, export destinations and information regarding the requirements of the importing
country must be supplied. For food factories which do not have the MOH Food safety
certification, the applications must be submitted to the district health office where the factory
is located at least 14days before the export date. The applicant must submit a sample taken by
authorised persons to the laboratory recognized by the Ministry of Health which have
beenaccredited by the department of standards, Malaysia. The product must comply with both
the Food Act 1983 and Food Regulations 1985. The materials, ingredients, chemical content
of the product must also be acceptable by the importing country. Health certificates are issued
based on the results of the analysis certificate and inspection report of the premise.After the
Health Certificate is issued, the product must reach its destination within a period of 6
months. Food factories which already have the MOH Food Safety certification will only need
to submit their health certificate application to the district concern within 3 working days.

BIL TYPES OF CERTIFICATE TYPES OF PRODUCT

1. Generalfoods Allkinds offoodexcept food listedin2, 3, 4.
2. Heat and freezing processedshrimp Shrimpproductsthathave
undergoneheatandfreezingprocess.
3. Edible palm oil, palm oleinandpalm stearin Palm oil products.
4. Heat processed meats Heat processed meats

5 Fish and Fishery Product for EU Fish and Fishery Product for EU

6 Food Contact Material (eg Food Packaging) Food Contact Material

Types of health certificates issued by the Ministry of Health

272
Objectives of the Health Certificate

The objective of the health certificate is to ensure that the food items or food contact
materials that will be consumed or used for export is safe and in good quality and the food
items that will be exported meets the standards set by the importing country's food law to
maintain Malaysia’s reputation in food industry capabilities.

Requirement for application of the health certificate

 Applications must be submitted before the product is exported

 Applicant is a registered company
 Products ready to export
 Destination and the name of the ship are known
 Information on the requirements of the importing country is known

The Health Certificate can only be used for exporting local products. Control of imported
products will be under the health department (port). Any manufacturer that has been certified
with Hazard Analysis Critical Control Point (HACCP) and Good Manufacturing Practices
(GMP) can obtain Health Certificates for product export immediately. However, these
factories will be required to be audited twice yearly. The manufacturer also has to fulfil the
regulations required in the HACCP or GMP.Among the requirements are metal detector (with
sensitivity of at least 10mm) to detect metal in food products (if there is need), hand washing
facilities at each entrance, freshly washed uniforms every day and set temperature and timing
of storage, cooking, chilling and packing to ensure consistency and safety.

C. Enforcement and Legal Unit

All the legal and enforcement activities involving Food Safety and Quality Control are
managed by the Enforcement and Legal unit e.g. to take legal action on the violations of food
samples taken by the enforcement officer, closure of dirty food premises and seizure of any
food found which is not fit for human consumption.

273
Food Quality and Safety Laboratory

Food Quality and Safety Laboratory (FSQL) was established in 1983 in Malaysia under the
supervision of the Ministry of Health (MOH) Malaysia. In the year 2001, Public Health
Laboratory (PHL) was formed and it works collaboratively with FSQL to ensure optimum
services in terms of food quality and safety is delivered to the public.The food quality control
laboratories provide services such as chemical, microbiological and physical analysis to
monitor food safety and quality. As of 2012, there were a total of 14 such labs in Malaysia;
10 Food Quality Control Laboratories (FQCL) and 4 Public Health Laboratories (PHL).Food
Quality Control Laboratory (FQCL) Butterworth is one of the oldest food quality control
laboratories, which was established under the Food Quality Control Division, Ministry of
Health Malaysia.The overall planning, development and coordination of activities in all labs
are the responsibilities of the Laboratory Section of the Food Safety and Quality Division.
Food quality testing can also be done in private labs which have the Department of Standards
Malaysia’s accreditation. Food quality testing laboratories must obtain Certificate of
Accreditation ISO/IEC 17025 from the Department of Standards.

The objective of the laboratoriesis to provide food analytical services based on the analytical
demands; resources planning (e.g. upgrading on modern equipment and hiring skilled
analytical technicians); ensure that the result of food analysis are done accurately and meets
the demand of the customers; investigate the causes and sources of food poisoning;
surveillance on food safety; ensure food products regulations regarding import and export are
fulfilled; provide microbiological and chemical analysis for surveillance and enforcement to
protect the public from the health hazards of food and fraud in the preparation, sale and
consumption of food; provide microbiological and chemical analysis of food received for the
purposes of enforcement in cases of crisis, outbreak and food poisoning; conduct research
particularly on issues of hygiene and food safety; and improve analytical capabilities to meet
the needs of the activities of Food Safety and Quality at the district level.

The activities of the laboratories include

 Conduct analytical activity -routine surveillance, outbreak, complaint & operations
 Implement ISO/IEC17025* to ensure quality of services and accuracy of results
produced
 Practice Standard Operating Procedures (SOP) for analytical methods and laboratory
procedures

274
  Optimize and update the use of information technology systems such as the Food
Safety Information System to facilitate data management and food sampling.
 Coordinates the analysis of food requirements for food safety activities with agencies
like Jabatan Kimia Malaysia and Institute Pengajian Tinggi Awam (IPTA) such as
Pusat Kawalan Doping, University Sains Malaysia to improve services and optimize
the use of food analysis and expertise of existing laboratory facilities.
 Collaborate with relevant agencies worldwide for the purpose of research, study and
improve the food.
 Collect and update information on private laboratories which have been accredited
under Jabatan Standard Malaysia for issuances of Health Certificates.
 Ensure that all laboratories participate in proficiency testing of national and
international levels to assess the technical skills in carrying out food analysis.
 Conduct audits in every laboratory to ensure the laboratory quality system is
implemented as prescribed.
 Monitor improvements and enhance capabilities of laboratories.
 Coordinate training and courses in related fields to continuously improve the skills of
analysis.
 Ensure that equipment’s in food laboratories are constantly upgraded in line with
current development in food analysis.

*ISO/IEC 17025 accreditation was obtained in July 2006 from Department of Standards Malaysia for 7
microbiological parameters analyses and 8 for chemicals. Harmonization of LQM, QSP and SOP, for all food
quality and safety laboratories, MOH Malaysia

Below is list of the common tests conducted in food lab after a premise inspection or after
obtaining a request for a health certificate for a food product

i. Food additives: preservatives, colourings, sweeteners, flavours etc.

ii. Microorganism: total plate count, coliform, S. Aureus, E. Coli etc
iii. Pesticide residues: organophosphorus, organochloride, synthetic pyrethroid etc.
iv. Drug residues: chloramphenicol etc.
v. Environmental contaminants: dioxins, PCSs, PAHs
vi. Shellfish toxins
vii. Metal contaminants: arsenic, cadmium, mercury, lead etc.
viii. Irradiated foods

275
 ix. Contaminants from packages and utensils
x. Canned food examination
xi. Genetically modified food
xii. Nutrients analysis
xiii. Food standard
xiv. Authenticity of food/fraud: meat species, shark fin

Figure below shows the work flow process of handling a sample in the food lab. If the sample
received by the food lab either from the consumer or from the district health officefulfils the
criteria(e.g.each sample must have a minimum weight of 250gm, placed in a sterile package
and sealed using the Ministry of Health seal. For Microbiological or Physical Analysis, only
one sample specimen is required), the sample is then temporarily stored and analysed through
microbiological test or chemical test based on the sample provided and once the analysis is
done the certificate of the analysed results are available to the consumer.

Upon receiving the sample all samples are registered and given a number. Sample
information will also be recorded into the sample custodian form. The following information
is vital
• Date the sample was taken
• The name of the sample
• Reference No of sample
• Type of packaging
• Sample weight
• Condition of the sample: temperature, official seal, samples labels.

Results of the microbiological analysis can be obtained 14 days after receiving samples.
Results of the chemical analysis will only be available 30 days after receiving samples.
However samples taken for crisis, outbreak of food poisoning is given priority.

The common microbiological analysis conducted in the laboratory includes

 Total Plate Count
 Coliform
 Coli

276
  S.aureus
 Bacillus cereus
 Salmonella
 Vibrio cholerae
 Listeria monocytogenes
 Vibrio parahaemolyticus
 E.coli 0157
 Yeast and Mould Count
 Sterility test
 Bacillus diarrhoeal toxin
 Staphylococcal toxin

The chemical and nutritional analysis conducted in the laboratory includes

 Preservatives - benzoic acid, ascorbic acid, formaldehide, sulphur dioxide, propionic
acid, prabens,boric acid and antioxidant (BHA, BHT, PG, TBHQ)
 Non-nutritive sweetener - Saccharin, cyclamate
 Synthetic colouring
 Pesticide residue - Organophosphate
 Heavy metal - Lead, Cadmium
 Food Standard - caffeine, iodine content in iodized salt, percent ash, percentage water,
percentage of soluble solids, percent nitrogen, percent acetic acid, percent fat, percent
of fish, the net weight etc
 Toxin - Aflatoxin
 Drug residue - Beta agonist, chloramphenicol, ractopamine

Food Analysis Unit

Implementation of quality system at the food laboratory.ISO 17025 accreditation under
Malaysia Standards to ensure

•Validity of results
•Reliability of laboratories

Harmonization of documents (e.g. records and reports) is done between:

•MOH food laboratories

277
 •Department of Chemistry, Malaysia

SAMPLING

TRANSPORTATION

SAMPLE RECEIVED
FROM LAB

NOT FULFILL
FULFILL CRITERIA CRITERIA

TEMPORARY STORAGE

MICROBIOLOGICAL
CHEMICAL ANALYSIS
ANALYSIS

ANALYSIS RESULTS

CERTIFICATE OF ANALYSIS

Figure showing the work flow process of handling a sample in the food lab

278
 CHAPTER 11: NUTRITIONAL PROGRAMMES

The general objective of the nutritional programmes in Malaysia is to achieve and maintain
optimal nutritional well-being of Malaysians, by improving the nutritional status of the
population and prevent and control diet-related diseases by the implementation of all forms of
nutrition-related activities.

Malaysia is currently an upper middle income nation and it intends to be a high income
nation by the year 2020. In the 70’s, Malaysia was predominantly a rural agricultural society
and half of all households were poor. Malaysia’s incidence of poverty reduced gradually over
the past five decades. The overall incidence for poverty for the years 1990, 2000, 2004, 2007
and 2008 were 49.3%, 16.5%, 5.7%, 3.6% and 3.8% respectively. The incidence of hard-core
poverty for 2004, 2007 and 2008 was 1.2%, 0.7% and 0.8 % respectively. The vast majority
of the poor households are Bumiputera who are mainly involved in the agricultural sector and
the Orang Asli (indigenous communities of peninsular Malaysia).

The Malaysian government has set a priority to reduce malnutrition and nutritional
deficiencies among young children and women of reproductive age. One of the strategies
employed includes conducting nutritional surveillance among children. This involves the
collection of data on the incidence of low birth weight and malnutrition in children. Another
effective strategy is the rehabilitation of malnourished children with the provision of food
supplements. A multi-sectoral approach is utilized to reduce childhood malnutrition and
nutritional deficit diseases and specific strategies are formulated to tackle iodine and iron
deficiency. As a result of a survey which showed that 12,000 children under the age 5 needed
urgent nutritional and health rehabilitation, a Nutrition Rehabilitation strategy was drawn up
with an initial grant of RM12 million. The ‘Food Basket’ programme which included
monthly provisions of food and nutrient supplements was an important component. The
children enrolled in this programme are regularly followed up and their physical and mental
development monitored. Growth Curve Charts were introduced in the mid-70s and was made
available as home based child health cards in the 1990s.

The nutrition programme in Malaysia is based on the National Plan of Action for Nutrition of
Malaysia (NPANM) in accordance with the National Nutrition Policy Malaysia. National

279
Plan of Action for Nutrition of Malaysia is a 10-year plan for the period 2006 to 2015. In
order to achieve and maintain the nutritional wellbeing of the population the National
Nutrition Policy Malaysia aims to provide guidance and facilities for all levels of society to
obtain adequate food supplies that is safe, high in quality and nutritious. This policy
encourages and supports healthy eating for all. It also integrate and consolidates efforts of
various organisations in the planning, implementation and evaluation of programs for food
and nutrition in an effective and sustainable manner.

The strategies of the National Nutrition Policy Malaysia includes- reaffirming the objectives,
considerations and components of food into the policies; ensure that all communities have
access to safe and nutritious food e.g. healthy school canteens project; ensure Malaysians
have access to nutritional education and resources to enable them to make informed decisions
concerning healthy food choices e.g. Malaysian food pyramid, reduce sugar campaign 2010;
prevent malnutrition and infectious diseases related to diet e.g. Iodine Deficiency Disorder
Control Programme; improving care for the less privileged and those at risk of malnutrition
e.g. children’s rehabilitation programme for nutritional deficiencies; promote optimal feeding
practices for infants and children e.g. code of ethics for infant nutrition marketing and related
products; promote healthy diet and active lifestyle in all segments of society e.g. nutrition
consulting services in Health Clinics (Klinik Kesihatan); support efforts to protect consumers
in improving food quality and safety e.g. health education in relation to food quality and
safety; ensure that nutrition and dietetics are practiced by trained professionals; enhance the
capacity of institutions in carrying out activities related to nutrition; continued assessment
and monitoring of the nutritional situation in the country; promote research and development
in the field of food and nutrition; and nutritional research priorities.

Nutrition Services in Health Clinic @ Klinik Kesihatan

The ministry of health started nutritional consulting services in health clinics in 2007 in
response to the incremental prevalence of diet-related chronic diseases. Among the strategies
included the placement of a nutritionist at respective participating clinics, to carry out
nutrition consultation and counselling. As of 2012, the nutritional consulting services have
expanded to 160 health clinics across Malaysia.

The services provided include dietary advice for patients with diabetes and pre-diabetic
adults, patients with gestational diabetes, adult hypertension, hyperlipidaemic patients (adults

280
and senior citizens), pregnant teenagers and anaemic individuals, weight management for
children, adolescents and adults who are overweight and obese and dietary advice for
children.

The objective of these services is to provide effective nutritional counselling by trained health
professionals using appropriate tools to individuals who have nutritional health related
problems particularly chronic diseases such as diabetes, hypertension, cardiovascular disease
and obesity.

Food Basket Programme (FBP)

Food Basket Programme is an initiative of the Ministry of Health Malaysia in overcoming the
problem of malnutrition of children aged 6 months to 6 years who came from hardcore poor,
poor or from easily poor households.

Realising substantial children especially from the rural and urban poor were malnourish, the
ministry of health started the Food Basket Program also known as Rehabilitation Program
with the objective to improve, within 6 to 12 months upon receiving the food basket, the
health and nutrition of underweight children below 6 years old who are from hard core poor
households.

The services under FBP include nutritional assessment which would include anthropometric
measurement, growth chart, BMI for age and a diet history to identify children who are
eligible under the programme. These children are monitored after the provision of the food
supplements. In addition to the nutritional education, the parent/caregivers are counselled to
ensure that the child achieves and maintains satisfactory nutritional status. Due to the efforts f
of this programme, under-five malnutrition has declined from 25% in 1990 to 5.7% in 2009.

Strategies

The strategy includes providing a Food Basket worth RM150 per basket every month for the
hard-core poor family with income of <RM 840.00 and also for those poor family under the
“1 Azam” project NKRA (Low Income Household) with income <RM 1500.00

Malnourished children who are eligible to be enrolled into the programme include children
between the ages of 6 months and 6 years old, from low socioeconomic status i.e. per capita
income of <RM 130 or family income of <RM 840 for peninsular Malaysia, per capita

281
income of <RM 140 and household income of <RM 1090 for Sabah and for Sarawak per
capita income <RM 150 and family income of <RM 920 (per capita is used when the family
comprises of more than 5 persons)*. Malnutrition is classified mild when the growth chart of
the child has weight for age less than ‘– 2 Standard Deviation (SD)’ and severe when the
weight for age is less than ‘– 3 SD’ from the median. They are registered in the HMIS and the
E-Kasih for further help from other agencies in the government. Each family is evaluated on
the housing and its environmental condition, water, sanitation and toilet/sewage system,
waste disposal system.

*these figures may change from time to time

Within a month of registration, the parents/guardians of the children are given one food
basket for each malnourished child either in the health clinic or in the child’s home if the
parents/guardian are unable to come to the clinic. The parents/guardian are advised, taught
and demonstrated on proper food preparation. The community nurse makes a monthly visit to
evaluate usage, storage of items, and carrying out cooking demonstrations. A nutritionist will
usually visit the affected family every 2 or 3 monthly.

The food basket will contain essential food and multivitamins. Food items are chosen based
on their caloric count, fat content, carbohydrate and protein. However the exact food items
may vary depending on the location, availability and requirement.

To help monitor the progress of the children who are on the food basket programme colour
codes are used- White for normal, yellow for mild and red for severe under nutrition.
Children coded yellow have to get an increment of weight on 3 consecutive measurements
and confirmation by a medical officer before the food baskets are stopped. Children in the red
zone have to get increment in weight on 6 consecutive measurements and confirmed by a
medical officer before the food baskets are stopped.

There are several obstacles in making the food basket programme a success including
negligence, abuse of the programme by selling or replacing the food items, sharing with
others who do not need the items and the attitude of the parents.

282
 Flow chart of handling malnourished children

Receive case

Antropometric screening and physical

assessment
No
Determine whether the child is Give advice on nutrition
malnourished appropriate to the child’s age

 Severe shrinkage  Shrinkage

 Marasmus or  Reduced weight
kwashiorkor Yes  Stunted and not
 Edema on the both overweight
legs  Trend towards one
of the above
problems

Refer to family Medicine Specialist or
Medical Officer

Investigate whether the child is sick or

having any chronic disease
Treat the child’s
Medical problem Yes disease or refer for
No
treatment
Inform the parents the cause of
malnutrition need to be determined

Investigate the child’s appetite

Advice to
increase breast- Yes Child loss of appetite
feeding or child’s No
food intake
Investigate eating habit of the child
Note: Malnutrition refers
Investigate if there is subsequent to one or more of the
infection following problem:
Investigate social and environmental  Less weight (Weight
factors for age < -2SD)
 Stunted
Identify the reason of malnutrition
(Length/height for age
< - 2SD)
Identify the action to be taken
 Shrink (BMI for age
Assessment < - 2SD)

Recover from malnutrition

283
Iodine Deficiency Disorder (IDD) Control Programme

Iodine is an essential micronutrient trace mineral which the body cannot make but is crucial
for the development and normal growth of most organs, metabolism and body temperature.
The human body contains 15 to 20 mg of iodine and almost 80% of it is located within the
thyroid gland. The World Health Organization reported that iodine deficiency is the most
important preventable cause of brain damage and developmental delay. Even moderate
iodine deficiency can cause a loss of 10 to 15 intelligence quotient (IQ) points. Hence it is
important to maintain an adequate iodine intake especially for pregnant women whose
iodine requirements are almost doubled. Babies born to iodine deficient mothers may be
lethargic and difficult to feed and if left untreated are more likely to develop mental
retardation and poor overall growth. Iodine Deficiency Disorders such as goitre,
hypothyroidism, and cretinism are easily preventable.

Epidemiology

Iodine deficiency is relatively common in developing countries. In Malaysia the prevalence

may range from almost zero in urban areas to more than 90% in some rural parts of Malaysia,
especially in Sabah and Sarawak. Iodine deficiency is especially a problem among the Orang
Asli in peninsular Malaysia. Women, more commonly pregnant women and older children
are more commonly afflicted with iodine deficiency than men.

A study which conducted in 1995 showed the prevalence of goitre among children aged 8 to
10 years old was 2.2% in Peninsular Malaysia, 17.9% in Sabah and 0.4% in Sarawak, with
some other states having percentages as high as 5%. The National IDD Survey conducted in
2008 showed that the median urinary iodine (UI) concentration amongst school children aged
8 to 10 years in Peninsular Malaysia, Sabah and Sarawak were 104.1, 150.2, 101.9 μg/l. In
Peninsular Malaysia, Kedah, Pulau Pinang, Perak, Pahang, Terengganu and Kelantan had
median UI concentration of less than 100 μg/l. In these states, more than 50% of the school
children had median UI concentration below 100 μg/l which suggested, iodine deficiency.

284
Median range in urine IDD (GAKI) Status Health Risks
(g/l)
< 20 g/l Severe Severe Iodine Deficiency
20 – 49 g/l Moderate Moderate deficiency
50 – 99 g/l less Less deficiency
100 - 199 g/l Optimum Optimum
200 – 299 g/l Over but still optimum Risk to have hyperthyroidism within 5-10 years after
consuming iodized salt
> 300 g/l Over optimum Risk to health due to excess iodine

IDD Programme
The objective of IDD programme is to reduce the prevalence of hypothyroidism among
pregnant women and infants. The strategy employed by the ministry of health is to supply
free iodinated salt to pregnant women and malnourished children. According to Food Act
1983 & Food Regulations 1985, iodinated salt is salt that had been added potassium
iodide/potassium iodate/sodium iodide/sodium iodate not less than 30mg of iodine/kg and not
exceeding 40mg of iodine/kg of salt. All clinics in the endemic areas are
supplied with iodized salt for distribution to pregnant women and malnourished children who
receive food baskets. Each person is allocated 500g of iodized salt and the salt is replenished
when it is finished. Iodinated salts are also supplied to schools canteens to increase the iodine
level among pupils. School canteen operators are taught how to use iodized salt – ideally add
the salt to the food when the food is ready. They are also taught to keep the iodized salts in
tightly closed containers, away from direct sunlight in a cool place. In high risk areas like
Sabah and Sarawak, households are monitored. Iodine is also added to the water used in
schools, long houses, rural areas and Orang Asli settlements. Prevention and control of iodine
deficiency is done through education and diet modification. Education regarding food
nutrition is done in schools and community clinics. Mothers and school children are told the
importance of iodine and disorders linking to iodine deficiency, goitrogenic foods and the use
of iodized salt.

285
Pamphlets on iodine by Ministry of Health Malaysia

Enforcement and monitoring of iodized salt is done to ensure that the level of iodine present
in foods is in accordance with the Food Act 1983. Enforcement and monitoring is done in the
factory, manufacturer, wholesale and retail outlets using Rapid Test Kit’s to ensure that salt is
iodized. Data is collected monthly to determine the distribution of iodized salt and the
amount used by the target groups. Urine samples taken from school children are either sent to
the Institute of Medical Research in Kuala Lumpur, or to other public health laboratories in
Ipoh, Sungai Buluh or Kota Kinabalu. At present the emphasis is placed on monitoring the
iodine levels in pregnant women to enable early management.

286
The food basket may contain

Type of food Pkt Pkt Pkt Pkt Pkt Pkt Pkt Pkt Pkt Pkt Pkt Pkt Pkt
1 2 3 4 5 6 7 8 9 10 11 12 13
Full Cream milk (2 X X X X X X X X X X X X
Kg )
Cereals (500 g) X X X X X X X X X X X X
Rice (5 kg) X X X X X X
Biscuit (2 kg) X X X X X X X X X X X X
Margarine (250 g) X X X X X X
Eggs (30 no’s) X X X X
Multivitamin X X X X X X X X X X X X X
(30 no’s)
Sardines X X X X
(7 small tin:155g/tin)
Anchovies (500g) X X X X
Bihun 3 kg : 7 pkt X X X X X X
@400 g/pkt
Cooking oil X X X X X X
(1 kg)
Chocolate Malt Power X X X X X X X X X X X X
(1 kg)
Special Milk 1 & X
Special Milk 2 (1.8
kg)

Breast Feeding Programme

Breastfeeding contains all the nutrients, antibodies, hormones and other factors hence it is the
perfect nutrition for infants’ healthy growth and development especially for the first six
months of life. Breast milk protects babies from diarrhoea and acute respiratory infections
and stimulates their immune system in response to diseases. WHO recommends that every
infant should be exclusively breastfed for the first six months of life, and continued
breastfeeding for up to two years of life. The National Health and Morbidity Survey (NHMS)
II in 1996 showed that 95% of Malaysian women breastfed their babies, while NHMS III in
2006 showed only 14.5% practised exclusive breastfeeding. The MOH formulated a National
Breastfeeding Policy in 1993 and revised it in 2005 in accordance with the World Health

287
Assembly Resolution 54.2 (2001) recommending exclusive breastfeeding in the first six
months of life and continued up to two years. In addition to the enforcement of the code of
ethics on breastfeeding, the Ministry of Health has widely implemented the Baby Friendly
Hospital Initiative since 1992. As of 2012, there are more than a 100 baby friendly hospitals
in the country mostly MOH hospitals.

The objective of the ministry of health’s breast feeding programme is to encourage all
mothers to exclusively breastfeed their babies for the first 6 months of life and only add
complementary food after 6 months and to continue breastfeeding until baby is 2 years old.

WHO recommends that - there should be a written breastfeeding policy which is routinely
communicated to all health care staff; all health care staff trained in skills necessary to
implement this policy; benefits and management of breastfeeding is conveyed to all pregnant
women; mothers should be helped to initiate breastfeeding within one half-hour of birth;
mothers should be shown how to breastfeed and maintain lactation even if they are separated
from their infants; mothers are told not give any food or drink besides breast milk to new-
born infants unless medically indicated; the practice of ‘rooming in’ i.e. mothers and infants
to remain together 24 hours a day is encouraged; encourage breastfeeding on demand; give
no artificial teats or pacifiers to breastfeed infants; and establish breastfeeding support groups
and refer mothers to them upon discharge from hospital/clinic.

In line with the UNICEF and WHO efforts in promoting all hospitals and maternity centres to
become a centre of breastfeeding support, one of the strategies adopted by the ministry of
health Malaysian is the implementation of baby friendly government hospitals. These
hospitals do not accept any free or low-cost breast milk substitutes or breast feeding
equipment’s. Expecting mothers in these hospitals are counselled concerning breastfeeding
and new mothers are taught on breastfeeding techniques. The mothers are told to initiate
breastfeeding within one hour after birth. They are taught the correct methods and the
comfortable positions of breastfeeding. Mothers are advised to breastfeed regularly and in
accordance with the baby’s needs. They are also told to exclusively breastfeed infants and
assured that the infant does not need any water or formula supplementation apart from the
breast milk. Malaysia also celebrates the World Breastfeeding Week in August every year
and implements the Code of Ethic for Infant Formula as recommended by the
WHO/UNICEF.

288
In 1998, Malaysia was declared by the WHO as the third country in the world which has all
its hospitals as baby friendly. The rate of babies who ever breastfed increased from 88.6% in
1996 to 94.7% in 2006 and the percentage of mothers who initiated breastfeeding within one
hour after birth also increased from 41.4% in 1996 to 63.7% in 2006.

Code of ethics for infant nutrition marketing and related products

The purpose of this Code of Ethics is to protect, support and promote breastfeeding practices
by controlling the pressure of marketing baby food products and equipment to breast-feeding
mothers. The code is based on the recommendations of the WHO’s “International Code of
Marketing of Breast Milk Substitutes” and the resolutions from World Health Assembly
(WHA) on infant feeding. The objective of the code is to promote safe and optimal nutrition
for infants by protecting and promoting breastfeeding, ensuring that when necessary due to
medical reasons, the use of breast milk substitute products are correctly recommended, and
sufficient and accurate information is provided especially concerning the control of
marketing and distribution of substitute products.

With the development of the code the parents will be able to make correct decisions
regarding infant feeding without the false and misleading advertisements in relation to the
benefits of breast milk substitutes. As a result the infants will receive the best nutrient
regarding breast milk which will impact growth and promote optimum health and eventually
help reduce malnutrition and mortality in infants and small children.

Strategies

All product information materials such as brochures, product labels and advertisements for
health professionals are screened and the approval of the Screening Committee Code of
Ethics for Infant Food Marketing and Related Products is sought. Monitoring of the
adherence to ethical practices of the dairy industry, personnel and health professionals and
disciplinary action for reported breaches of the Code of Ethics are carried out. Penalties
depend on the extent and frequency of breach.

The penalties may range from written warnings to the company by the Chairman of the
Ethics Code of Marketing of Baby Food and Related Products at the state level, suspension of
all new materials for one to two years, notification to the World Health Organization (WHO)

289
and UNICEF, notification to the International Association of Infant Food Manufacturers,
issuing a press statement and blacklist and boycott of the company's tender for a certain
period of time.

290
 CHAPTER 12: OCCUPATIONAL HEALTH

INTRODUCTION
A joint ILO and WHO Committee on Occupational Health- in their 1st meeting described
occupational health as ‘Occupational Health should aim at – the promotion and maintenance
of the highest degree of physical, mental and social well being of workers in all occupations;
the prevention among workers of departures from health caused by their working conditions;
the protection of workers in their employment from risks resulting from factors adverse to
health; placing and maintenance of a worker in an occupational environment adapted to
his physiological and psychological equipment and, to summarize, the adaption of work to
people and of each person to their job.‘ The first part of this statement is generally mentioned
as the definition of occupational health.

The main trust of discipline of occupational health is to prevent ill health rather than to cure
it. This involves the prevention of negative health related effects amongst workers in their
work environment by protecting the workers from risk factors at work and placing and
maintaining the worker in an occupational environment adapted to his physiological and
psychological capabilities. In summary-ensuring that the worker remains fit and well whilst
undertaking the tasks he or she is employed to perform by the establishment and maintenance
of a safe and healthy working environment.

Occupational Medicine is the branch of clinical medicine most active in the field of
Occupational Health. Its principal role is the provision of health advice to organizations and
individuals to ensure that the highest standards of Health and Safety at Work can be achieved
and maintained. So occupational physicians must have a wide knowledge of clinical
medicine and be competent in a number of important areas. The aims of occupational health
is the prevention of disease and the maintenance of the highest degree of physical, mental and
social well-being of workers in all occupations; and levels of application of preventive
measures- health promotion, specific protection, early diagnosis and treatment, disability
limitation and rehabilitation. For the promotion and maintenance of the health of the workers,
a special health service is essential for them. WHO has identify the following basic principles
for the development of Occupational Health services in a country, namely (a) It must be
ensured that occupational health services are provided through the existing national health

291
services; (b) The service must provide for the health of the workers and if necessary for their
families; and the PHC approach must be the chosen system for delivery of such services.

Occupational Epidemiology: Occupational epidemiology is the application of

epidemiologic methods to population of workers. Occupational epidemiologic studies may
involve looking at workers exposed to a variety of chemical, biological or physical agents
(hazards) to determine if the exposures result in the risk of adverse health outcomes.
Alternatively, epidemiologic studies may involve the evaluation of workers with a common
adverse health outcome to determine if an agent or set of agents may explain their disease.
Occupational environment is the core component of occupational epidemiology.
Occupational Environment means the sum of external conditions and influences which
prevail at the place of work and which have a bearing on the health of the working
population. There are three types of interaction in a working environment that would clearly
describe the occupational epidemiological process, namely (a). Man and agents (physical,
chemical and biological); (b). Man and machine (equipments) and (c). Man and man
(coworkers, supervisors and authorities).

Man and agent factors: Physical agents or factors include heat, cold, humidity, air
movement, heat radiation, light, noise, vibration and ionizing radiation and other factors like
working spaces and personal facilities that acts in different ways on the health and efficiency
of the workers. The chemical agents are a large number of chemicals, toxic dusts and gases
etc causes disabling respiratory illness, injury to skin and some have deleterious effect on
blood and other organs. Biological factors include bacteria, virus, rickettsia; parasites etc
come in contact with workers through animals or their products, contaminated water, food or
soil.

Man and machine factors: machine factors may be unguarded, protruding and moving parts,
poor installation of the plant, lack of safety measures and Man facorts in this regards are
working long hours in unpleasant posture causes fatigue, backache, diseases of joints,
muscles etc. leads to accident.

Man and Man factors in modern occupational health emphasis is given upon the people, the
conditions in which they work and live, their hopes and fears and their attitudes towards their
jobs, their fellow-workers and employers. Psychological factors had impact on the

292
occupation. Human relationship among the workers and those in authority over them are
important. These include type and rhythm of work, work stability, service conditions, job
satisfaction, leadership styles, securityWorkers participation, Job satisfaction, Leadership style,
security, Workers participation, Communication, system of payment, welfare conditions,
degree of responsibility, Trade union activities etc.

Hazards
A hazard is any source of potential damage, harm or adverse health effects on something or
someone under certain conditions at work. An industrial worker may be exposed to different
types of hazards depending on his occupation: These may be
1. Physical hazards; e.g. heat, cold, light, pressure, noise, radiation, mechanical factors
etc.
2. Chemical hazards; e.g. gases, dusts, metals, chemicals and solvents.
3. Biological hazards; e.g. brucellosis, leptospirosis, etc.
4. Mechanical hazards; e.g. round machinery, protruding and moving parts and the like
and
5. Psychological hazards; e.g. frustration, lack, of job satisfaction, insecurity, poor
human relationships, emotional tension.
6. Ergonomic - repetitive movements, improper set up of workstation, etc

Management of health hazards

The management of health hazards related to occupational health includes

1. Elimination of hazard - is the process of removing the hazard from the workplace. It
is the most effective way to control a risk because by elimination of the hazard risk is
no longer present. It is the preferred way to control a hazard and should be used
whenever possible e.g. anon-essentialhazardous chemical which is used for work
activity or process should be eliminated wherever practicable.
2. Substitution-substitute the hazardous material with something less hazardous.
Substitution is used for substances that are carcinogenic, toxic to reproduction,
allergenic or neurotoxic. Substitution may mean the substitution of materials or
substitution of process/equipment or both e.g. the substitution of DDT with
pyrethrins.

293
 3. Isolation-involves removing the source of hazard exposure from the worker’s
environment. Isolation includes
 placing the source and the workers in different locations to avoid them coming
in contact with each other.
 enclosing/shielding the source with physical barriers
 automation or separation of the process from people i.e. the worker in an
enclosed system or separated by a barrier
 removal and storage of these materials in a separate location
 contaminant-free booth either around the equipment or worker e.g. negative-
pressure fume hoods in laboratory settings
4. Engineering control- are plant, processes or equipment that suppress or contain
hazardous substances that minimise the generation of hazardous substances or limit
the area of contamination in the event of spills or leaks. Engineering controls include
enclosure or partial enclosure, ventilation, automation of process and water spray e.g.
using material handling equipment rather than have workers lift, lower, carry,
materials manually etc.
5. Administration-administrative measures include safety training, safe operation
procedure (SOP), regular maintenance of the equipment, job rotation and counselling
programme
6. Personal Protective Equipment (PPE)- equipment’s that protects the worker against
one or more occupational risk e.g. safety helmet, boots, apron, respirator, ear
muffle/plugs etc.

OCCUPATIONAL DISEASES:
Occupational diseases are defined as diseases arising out of or in the course of employment.
It depends on the agent factors the workers exposed.

A. Diseases due to physical agents

1. Heat- burn, Heat hyperpyrexia, heat exhaustion, heat syncope, heat cramps etc
2. Cold- trench foot, frost bite, chilblains.
3. Light- occupational cataract, Miner's nystagmus.

294
 4. Pressure- Cassion disease, air embolism, blast (explosive).
5. Noise- occupational deafness.
6. Radiation- cancer, leukaemia, aplastic anaemia, pancytopenia.
7. Mechanical factors- injuries, accidents.
8. Electricity-burns.
B. Diseases due chemical agents:
1. Gases- CO2, CO, HCN, CS2, NH3, N2, H2S, HCl, SO2 etc these causes gas poisoning.
2. Pneumoconiosis dust diseases
i. in-organic dusts:
a. Coal dust………..Anthracosis.
b. Silica……………..Silicosis
c. Asbestos…………Asbestosis, Cancer lung.
d. Iron…………..…..Siderosis.
ii. Organic [Vegetable dusts] dust-
a. Cane fiber ……….…….Bagassosis
b. Cotton dust…………….Byssinosis
c. Tobacco………………..Tobacossis
d. Hay or grain dust……..Farmers’ lung.
3. Metals and their compounds: Toxic hazards from lead, mercury, cadmium,
manganese, beryllium, arsenic, chromium etc.
4. Chemical: Acids, alkalies, pesticides.
5. Solvent: Carbon bisulphide, benzene, trichloroethylene, chloroform etc.

C. Disease due to Biological Agents: Brucellosis, Leptospirosis, Anthrax, Actinomycosis,

Hydatidosis, Psittacosis, Tetanus, Encephalitis etc.
D. Occupational Cancer: Cancer of Lungs, skin, Bladder and Haemopoietic cancer.
E. Occupational dermatosis: Dermatitis, Eczema.
F. Diseases of Psychological origin: Industrial neurosis, Hypertension, Peptic ulcer etc.

295
COMMON OCCUPATION DISEASES AND DISORDERS

1. Thermal Disorders

Humans like animals have the ability to maintain their body temperature within narrow
limits, this characteristic is known as homeothermy. Failure to maintain the body temperature
within a degree or two of the 37 C may result in serious consequences. Heat illnesses include

 Heat stroke: elevation of core body temperature exceeding 41.1ºCleading to tissue

damage often of irreversible nature.
 Heat exhaustion: failure to adjust for the shift of blood to the skin as a result of the
dilatation of the skin blood vessels. It is frequently linked to dehydration.
 Heat cramps: results from sodium depletion
 Heat syncope: sudden unconsciousness resulting from cutaneous vaso-dilatation with
consequent systemic and cerebral hypotension.
 Skin disorders: miliria (heat rash), erythema abigne, intertrigo, heat urticarial etc.

2. Occupational Overuse Syndrome

Also known as repetitive strain injury is usually due to posture, movement and force,
nature and technique of work and psychological factors.

3. Vibrational Disease

Only vibrational frequencies up to 80 Hz are considered to be harmful to the whole body

whereas frequencies is up to 2 KHz may be damage the hand and arm,.

4. Occupational Hearing Loss

Occupational hearing loss is the partial or complete hearing loss in one or both ears
arising in or during the course of and as a result of one’s employment including acoustic
trauma, traumatic injury and Noise Induced Hearing Loss (NIHL) which results from a
life time of cumulative exposure. NIHL usually affects both ears equally in extent and
degree.

5. Occupational Lung Disease

Occupational lung diseases are an acute or chronic disorder that arises at least partly from
inhalation of an airborne agent in the workplace. Pneumoconiosis is a group of non-
296
neoplastic occupational lung diseases due to hazardous effect of dust ranging from size 0.5
to 3 micron that cripple men by reducing working capability causes permanent lung fibrosis
and for other complications like asthma, bronchitis and emphysema . There is no curative
treatment of pneumoconiosis even abstaining from work, prevention and protection of
workers from dust is the only measure. The important dust diseases are Silicosis, Anthracosis,
Byssinosis, Bagassosis, Asbestosis and Farmer’s lung. The hazardous effects of dust on lungs
depend on Chemical composition of dust, fineness of dust, Concentration of dust in the air,
Period of exposure and Health status of the person. Silicosis is caused by inhalation of dust
containing Silica or Silicon dioxide in mining industry, pottery and ceramic industry, sand
blasting, metal grinding, iron and steel industry, building and construction works and others.
It leads to dense nodular fibrosis of the lungs and on X-ray ‘snow-storm’ appearance with
clinical complains of irritating cough, dysponea on exertion, chest pain, and ultimately
impairment of total lung capacity. Anthracosis is called Coal miners’ pneumoconiosis.
Byssinosis occurs for inhalation of cotton fiber dust over the prolong periods of time. The
symptoms include chronic cough and progressive dysponea, ending in chronic bronchitis and
emphysema. Bagassosis is caused for inhalation of bagasse or sugar-cane dust. The sugar-
cane dust contain thermophilic actinomycete ‘Thermoactinomyces sacchari’ that causes acute
diffuse bronchiolitis and for long exposure leads to haemoptysis, diffuse fibrosis, emphysema
and bronchiectasis. X ray shows mottling in lungs is the typical feature. Asbestosis occurs for
asbestose fiber inhalation most common in. asbestos cement, fireproof textiles, roof tiling,
and brake lining, gaskets workers.Farmer’s lung occurs in farmers for inhalation of
thermophilic actinomycetes (Micropolyspora faeni) present in grain and hay dust.

6. Occupational Dermatoses

Occupational dermatoses are disorders of the skin caused by or made worse by the
components of the workplace environment. Included are contact dermatitis (irritant
dermatitis, allergic dermatitis), photodermatitis, urticaria, pigmentary disorder (vitiligo),
acne, cutaneous neoplasm etc.

7. Carcinogenesis

80% - 90% of carcinomas are environmentally caused including the work environment.

297
 8. Zoonoses

Zoonoses are communicable diseases and parasitic infestations which are transmitted
between the vertebrate hosts and man.

9. Musculoskeletal Injuries

These include sprains, overuse injury, tendonitis, carpal tunnel syndrome and soft tissue
injury.

10. Ionizing And Non Ionizing Radiation

A major constituent of the annual average dose received by the population comes from
natural radiation; these sources include the external sources i.e. cosmic rays, radioactive
substances in the ground and building materials and internal sources resulting from the
inhalation or ingestion of materials naturally occurring in air or food. The detrimental
effects of ionizing radiation are acute including skin erythema, bone marrow depletion,
reduction in fertility, acute radiation syndrome and late effects including cataracts,
hereditary effects, carcinogenic and mutagenic affects.

11.Occupational Stress: Occupational stress may produce both overt, psychological and/or
physiological.

Health Problems due to Industrialization:

1. Environmental sanitation related to housing, water pollution, air pollution and sewage
disposal.
2. Communicable diseases oy- T B, STDs, food & water borne diseases, vector borne
diseases etc.
3. Mental illness- due to failure of adjustment in living and working condition - mental
illness, behavioural disorder, psychoneurosis, delinquency etc.
4. Accident- within the industrial unit and also outside.
5. Social problems- alcoholism, drug abuse, gambling, breaking up of homes, increased
divorces, prostitution, increased crime etc

298
6. Increase morbidity and mortality- chr bronchitis and cancer.

Measures for General Health Protection of workers

The ILO / WHO committee on Occupational Health (1953) made the following
recommendations.
1. Nutrition: provision of balanced diet through subsidized canteen and education on
Nutrition.
2. Communicable disease control: includes early diagnosis, treatment, prevention and
rehabilitation of communicable diseases e.g T B, STDs, food & water borne diseases,
Environmental sanitation-
3. Environmental sanitation-

I. safe water supply,

II. food sanitation and nutritional education,
III. sufficient numbers of sanitary latrine and urinals for both sexes,
IV. general cleanness of the industrial establishment
V. Sufficient floor spaces [500 c ft / capita], adequate lighting, proper
ventilation, and adequate temperature maintenance,
VI. Protection against hazards e.g. dusts, fumes and toxic substances.

4. Mental health-
i. To promote the health and happiness of the workers
ii. To relieve the stress and strain
iii. Treatment for mental illness
iv. Rehabilitation
5. Measures for women and children-
i. Maternity leave for 16 weeks [8+8]
ii. Free ANC, INC & PNC services
iii. Prohibition of night work and carrying excessive weights
iv. Adequate management for nursery for the children of working mothers
v. Not employing children under 14 years
6. Health education- for all levels viz.
i. the management,

299
 ii. the supervisory staffs,
iii. the workers,
iv. the trade union leaders and
v. the community.

Occupational Health and the WHO

The main functions of WHO in relation to occupational health include promoting the
improvement of working conditions and other aspects of environmental hygiene. The WHO
is implementing a Global Plan of Action on Workers’ health 2008-2017 endorsed by the
World Health Assembly in 2007 with the following objectives

1. Devising and implementing policy instruments on workers' health

2. Protecting and promoting health at the workplace

3. Improving the performance of and access to occupational health services

4. Providing and communicating evidence for action and practice, and

5. Incorporating workers' health into other policies.

Occupational Health in Malaysian

The major responsibility for Occupational health and Safety is under the Ministry of Human
Resources and is mainly concerned with the safety and health. In the Ministry of Health the
division of safety and health concerns with occupational health. In the ministry of health the
occupational health team comprises of occupational health doctors, nursing sisters, nurses,
assistant environmental health officer and assistant inspector of factories and machinery. The
main objectives of the division are to enforce occupational health related legal requirements
and encourage the adoption of health promotion and health protection in all workplaces.
Occupational health division is divided into Occupational Medicine Section and
Accreditation Section.

Functions of Occupational Health Division

The functions of the occupation health division is to

300
 1. monitor occupational diseases and poisoning notifications reported and assist in the
investigation of diseases and poisoning in their respective states
2. monitor the investigation of occupational related diseases in the respective states
3. conduct investigations of occupational diseases for ex-gratia compensation of
government employees in collaboration with the Ministry of Finance
4. analyse occupational diseases and poisoning reports from the states and prepare
compilation reports
5. advice state officials, outside agencies, health practitioners and those related to
occupational health.
6. register and renew the certificate of Occupational Health Doctors (OHD) under the
Use and Standards of Chemicals Hazardous to Health Regulations 2000 (USECHH
2000 (accreditation division))
7. monitor health and medical surveillance activities of the OHD’s (accreditation
division)
8. planning seminars, courses or dialogues for improving occupational health awareness
(accreditation division) and
9. assist in the implementation of the industry Code of Practice for HIV/AIDS and drug
and alcohol in the workplace.

Some measures implemented by the Ministry of Health to prevent hazards at the

workplace include

 environmental monitoring e.g. workplace inspection (Safety and Health Audits)

 employee health monitoring e.g. regular health check-up
 education and training for workers e.g. courses, workshops, campaigns
 providing health Guidelines e.g. pamphlets, posters, SOP
 law enforcement and committees e.g. Health and safety policy and ‘Jawatankuasa
Keselamatan dan Kesihatan Pekerja’(organisation safety and healthcommittee)
 safe equipment and machines maintenance
 appropriate warning signs and labelling at risk areas
 good waste disposal practice including schedule waste

301
Notifiable Hazards

The Occupational Safety and Health Act of 1994 (Act 514) requires an employer to notify to
the nearest District Health Office(Kesihatan Pekerja dan Alam Sekitar (KPAS) unit) which
forwards

Human Immunodeficiency
virus (HIV), methicillin
Infectious / biological agents, such as bacteria, viruses, fungi, or resistant staphylococcus
parasites aureus (MRSA), hepatitis
Biological
B virus, hepatitis C virus,
tuberculosis etc

Ethylene oxide,
Chemical
formaldehyde,
Toxic chemicals like medications, solutions, and gases or chemicals glutaraldehyde, waste
which can be explosive, flammable, toxic, corrosive or harmful anesthetic gases, hazardous
drugs such as cytotoxic
agents .

Psychological
Bully, stress, violence, shift
Factors and situations that can create or potentiate stress, emotional
work, inadequate staffing,
strain, and or other interpersonal problems due to work environment
heavy workload

DANGER OF Radiation, laser, noise,

FALLING electricity, extreme
Physical MATERIALS Agents within the work environment that can cause tissue trauma
temperature Ionizing
KEEP CLEAR radiation, e.g. x-rays

Ergonomics
May affect the muscle,
nerves, tendons or ligament.
include manual handling, repetitive movement, forceful movements Due to improper work
and awkward posture. methods and improperly
designed work stations,
tools and equipment’s.

Table showing common types of hazards in occupational settings

302
the notification to the state authorities and Ministry of health of any accident, dangerous
occurrence, occupational poisoning and occupational disease that occurred in the
workplace.Only major occupational health related events are reported to the Department of
Occupation Safety and Health (DOSH).The Act also stipulates every registered medical
practitioner or medical officer attending to, or called in to visit a patient whom he believes to
be suffering from an occupational disease or poisoning to report the matter to the Director
General.The Occupational Safety and Health (Notification of Accident, Dangerous
Occurrence, Occupational Poisoning and Occupational Disease) Regulations 2004
[NADOPOD] provides further requirement and information on the notification method,
procedure and process to be followed by the employer and the medical practitioner in
pursuant to the requirements of section 32 of Act 514.

KPAS
KPAS is an abbreviation for ‘Kesihatan Pekerjaan dan Alam Sekitar’ (Occupational and
Evironemental Health) and was established in the Ministey of Health to promote and
maintain the physical and mental health of workers, and to ensure the environmental safety.
KPAS is governed under the Occupational Safety and Health Act (OSHA) 1994 and
Regulations under the Department of Occupational Safety and Health (DOSH) which is a
department under the Ministry of Human Resources. DOSH is responsible in ensuring the
safety, health and welfare of people at work as well as protecting the public from the health
hazards arising from these activities. This includes increasing the awareness and knowledge
of the workers to the risks and hazards that they are exposed to in their working environment.
The health and safety of workers in homecare, kindergartens, and homes are looked within
their jurisdiction. All violations of the Occupational Safety and Health Act in hospitals and
other health care settings is reported by health officers from the KPAS unit to the Department
of Occupational Safety and Health (DOSH).

The objectives of the unit are to carry out effective interventions and to have a good

303
monitoring system of environmental hazards and to ensure availability of sufficient human
resources, technical and laboratory support and services in handling environmental issues;
and to prevent health problems related to work conditions, practices and environment and to
prevent morbidity and mortality caused by occupational diseases, injury and poisoning. This
is achieved by increasing the awareness and knowledge among workers, employers and
public regarding occupational health and safety.

The main scope of function of KPAS is

1. Injury surveillance among health care workers e.g. sharps injury surveillance
2. Occupational disease and poisoning surveillance
3. Provide service in occupational health e.g. Occup Health Clinic
4. Increase awareness and promotion of occupational health and safety e.g. safety and health
campaigns
5. Carry out occupational health and safety audits and risk assessment in the workplace
6. Meetings and continuous medical education e.g. safety and health courses, talks
7. Chemical health risk assessment at workplace e.g pathology department

Jawatankuasa Keselamatan dan Kesihatan Pekerjaan JKKP)

Under Section 30(1) of Occupational Safety and Health Act,states that every employer must
form a committee for JKKP if there are 40 or more workers or if instructed by Director
General Deparement of Occupational Safety and Health. The JKKP committee consists of a
chair person with a secretary and two representatives (the employer and worker).

Jawatankuasa Keselamatan dan Kesihatan Pekerjaan (JKKP) is a committee consisting of

representatives of employers and employees working together to improve occupational safety
and health at work.JKKP members are responsible and accountable for all decisions related to
occupational safety and health. The objectives of the JKKP are to encourage engagement
between employer and workers in order to increase occupational safety and health in
workplace, create two-way communication between employer and workers for a better
delivery of information and issues related to occupational safety and healthand encourage
employers and administration team towards creating a safe and healthy workplace condition.

304
The function of JKKP is to
 identify health and safety hazards at work place and design an effective response
system.
 conduct surveillance on compliance towards occupational safety and health measures
 collect, investigate and prompt handling of report and complaints regarding
occupational injury and safety issues
 accompany the officer from Department of Safety and Occupational health on
inspection at premise.
 advice on personal protective equipment and other safety equipment required by the
workers.
 give recommendations to employer on policy and programs in term of maintenance
and upgrading the safety measures at workplace.

CHAIR PERSON

HH SECRETARY

WORKER

REPRESENTATIVE REPRESENTATIVE

Composition of the JKKP Committee

Courses on occupational health and safety and infection control a conducted once every 6
months to promote occupational safety and health awareness among the district health office
employees. Topics covered during the course include the introduction to occupational safety
and health act 1994, notification of injuries, accident and infection and needle prick injury.
Internal training on occupational health and safety by the district KPAS unit are also
conducted e.g. course on handling of fogging machine and poisonous spray - personal
protective equipment used by foggers, proper storage of poisonous pestisides; basic CPR
course once a year for all Pejabat Kesihatan Daerah (District Health Office) staff, ‘Stop

305
Smoking Programme’, healthy lifestyle campaings for all the health staff; Fire safety training
- conducting activity on fire safety which includes fire drill and briefing on fire safety and
demonstration on how to put off the fire. External training on occupational health and safety
is also provided by experts invited from outside the system.

Penalty
Failure to comply to any of the rules under ‘Peraturan-peraturan Keselamatan dan Kesihatan
Pekerjaan1996’ will cause result in a fine not more than RM 5,000 or jail not more than 6
months or both.

Health care facility safety and health audits

Audits are carried out to assess the standards and quality of the working environment and to
ensure the standards are being followed. The below 2 shows the scoring system used as a
guideline for the evaluation of a health care facility during an audit as laid out by the ministry
of health guidelines.

Score% Evaluation Frequency of Audit

>75 Good 3 years
50-75 Satisfactory 2 years
<50 Non-satisfactory 6 months

All health facilities are audited either by appointment or as a surprise visit by the KPAS unit.
A report along with the recommendations is prepared and handed to the Medical Officer of
Health who is responsible for taking appropriate actions. The audit is declared end if the
score is above

306
The following flow chart shows the steps Of Health Care Facility Audit conducted at the
district level by the KPAS unit.

Appointment made by email or phone (*2 weeks in advance)/or/Surprise visit

Audit

Report and Suggestion

Inform District Health Officer

Appropriate End of Audit

Re inspection
measures taken

Flowchart of Action of an Healthcare worker after sustaining injury

Needle Stick Injury or Sharps injury

Needle stick injury or sharps injury is the commonest type of occupational injury in a health
care setting. “Sharps” includes all sharp instruments/ devices used in healthcare facilities (e.g.
all types of needles, scalpel, broken glass, lancet and other sharps device). The actual risk of
transmission of a blood borne pathogen following a needle-stick is extremely low. The most
commonly transmissible diseases of concern to health care workers are

Hepatitis B: risk of infection following a needle stick injury is around 6-30%.

Hepatitis C: risk of infection from HCV following a needle-stick is around 1.8%

HIV:risk of becoming infected with HIV is 0.3%.

307
Management of sharp injuries

The hierarchy of controls for needle stick injury from most effective to least effective is

1. Elimination of Hazard-Substitute injections by administering medications through

another route, such as tablet, inhaler, or transdermal patches when possible.
2. Engineering Controls- Use “safer medical devices”, such as sharps with engineered
sharps injury protections and needleless systems. These devices have built-in safety
features that reduce the risk of injury and can include syringes with a sliding sheath,
needles that retract into the syringe after use, shielded or retracting catheters, and IV
systems that use a catheter port with a needle housed in protective covering.
Needleless systems include IV’s that administer medication and fluids through a
catheter port using non-needle connections and jet-injection systems that deliver
liquid medication beneath the skin or through a muscle. Jet injectors may substitute
syringes. Using needles and other sharps with integrated safety features e.g. blunt
stitch needles. Use of puncture-proof containers to dispose of sharps and needles.
Containers must be closed, puncture resistant, leak proof, colour coded, and emptied
routinely to prevent overfilling.
3. Administrative Controls - Policies formed to limit exposure to the hazard. This
includes the formations of a needle stick prevention committee, an exposure control
plan, removal of all unsafe devices, training on the safe use of devices etc. These
interactive training on the use of safer devices, work practices, and PPE are conducted
by a knowledgeable person. Workers receive the training when hired and at least once
a year, or whenever there is a modification of tasks or procedures. Training is
provided during working hours and at no cost to the employees. Training records are
maintained for future references. All documents and records are kept including a
written Exposure Control Plan (ECP). This ECP must be reviewed and updated
annually or more frequently whenever new or modified procedures are adopted or
whenever employee positions are revised in such a way that creates new potential
exposures. This review includes an examination of the most recent technological
advances. The workers must be informed of the location of the ECP and the
procedures to follow if an exposure occurs. Record keeping is essential. A sharps
injury log which must contain at a minimum, date of the injury, type and brand of the

308
 device involved, department or work area where the incident occurred and
explanation of how the incident occurred. Standard Operating Procedures including
no re-capping, placing sharps containers at eye-level and at arm’s reach, emptying
sharps containers before they're full, and establishing the means for safe handling and
disposing of sharps devices before beginning a procedure are part of the
administrative controls. Hepatitis B: Due to high risk of Hepatitis B viral infection in
the hospital setting, health care workers are usually given Hepatitis B vaccination to
minimize the risk of getting infected from a Hepatitis B patient.
4. Personal Protective Equipment (PPE) - includes barriers and filters between the
worker and the hazard. PPE’s include gloves, gowns, eye goggles, masks or face
shields. This equipment must be in appropriate sizes that fit all workers, of good
quality and must be readily available. Non-latex alternatives must also be provided.
Where PPE is used, employers should ensure that it is properly selected for the
individual and task, readily available, clean and functional, correctly used when
required, maintained by trained staff in accordance with PPE maintenance and
servicing program and employees are given training on the use and shelf life of PPE.
Emphasis should be given to the most critical part of the respiratory and dermal
protection.

Type of PPE Actions

Gloves -sterile gloves for aseptic procedures.
-disposable gloves when touching blood, body fluids,
secretions, mucous membranes, non-intact skin,
excretions and contaminated items.
-removed after touching these materials.
-change between procedures/patient contacts
-discard after procedures
Mask/goggles/face shields -when performing patient care procedures which
generates splashes of blood, body fluids, secretions
and excretions
Plastic aprons/gowns -disposable
-change after each patient/procedure
Rubber boots/overshoes -if gross contamination or spillage to foot/leg is
expected

Table showing the common Personal Protective Equipment used by the health care workers

309
Needle stick injury

In an event of a needle stick injury the emergency measures on sharp/needle sticks injuries
include squeezing out blood as much as possible, washing hand with soap and water, wipe
affected site with antiseptic, cover with dressing if necessary, report to supervisor
immediately. Risk assessment procedure are carried out - HIV, HBV and HCV status of the
source of the blood is determined and baseline testing for HIV, HBV and HCV of the
affected health care worker is conducted and if indicated, post-exposure prophylaxis
treatment can be commenced

310
 CHAPTER 13: WATER SUPPLY AND ENVIRONMENTAL
SANITATION

Water and sanitation is an important element of health for any human settlement
infrastructure. The lack of access to safe drinking water, suitable sanitation and satisfactory
waste management increases the risk to life threatening diseases. The Millennium
developmental goal 7, target 7 c advocates that by 2015, the proportion of people without
sustainable access to safe drinking water and basic sanitation should be halved. Access to
safe drinking-water and to basic sanitation is measured by the proportion of population using
improved drinking water source and the proportion of the population using improved
sanitation facility.

Understanding the importance of water and sanitation to the health of its citizens, the
government has been actively promoting environmental sanitation since the 1970’s. 98% of
urban and 92.6% of rural populations are now served with treated piped water and almost the
entire urban population has been supplied with reticulated sewerage systems and septic tanks
by local authorities, and in rural areas, sanitary latrines has been provided for 99% of the
population. This increased access to clean water and proper sanitation has resulted in the
reduction in the spread of infectious diseases like cholera, typhoid, and dysentery in
Malaysia, especially among the rural communities.

Bekalan Air dan Kebersihan Alam Sekitar (BAKAS)

BAKAS is the rural water supply and sanitation programme implemented by the Ministry of
Health Malaysia, the objective of BAKAS is to help control and reduce infectious diseases,
especially food and water-borne illnesses in the rural settings by providing safe water supply
and proper sanitation system.

The specific objectives of BAKAS is to; ensure that the residents in the rural areas get clean,
safe and adequate water supply; ensure every house have and use a proper toilet; ensure every
house has a system for their domestic water usage and a well-ordered solid waste disposal
and that the surrounding area is unpolluted; help residents increase their awareness and

311
knowledge regarding the importance of unpolluted environment: and provide guidance and
technical education in carrying out BAKAS projects.
Projects under the jurisdiction of BAKAS include

 Building ‘pour flust toilets’ (tandas curah)

 With financial support from the Ministry of Rural and Federal Territories Development
(Kementerian Kemajuan Luar Bandar dan Wilayah) and with the cooperation of
Ministry of Health and the Water Works Department (Perbadanan Bekalan Air),
qualified contractors lay and connect water pipes
 Proper disposal of used water disposal (air limbah) – currently filtration method is used
 Solid waste disposal (pelupusan sisa pepejal)

Pour flush toilets (Tandas Curah)

One of the most important activities of BAKAS in order to control water borne infections like
cholera and dysentery is the construction of pour flush toilets in rural areas. Prior to this
activity, rivers and open grounds were used as toilets by those living in rural areas. When
human waste enters the river networks it pollutes the rivers and produce bad odour. Residents
living downstream of the rivers are exposed to the contaminated water and become at risk of
water borne diseases. Realizing this, the ministry of health has actively been providing
sanitary toilets in every house. Picture 1 & 2 shows the toilets built by villagers compared to
picture 3 of a toilet built by BAKAS.

312
 Picture 1 Picture 2

Picture 3

Manhole

outlet

313
Clean Water Supply (Bekalan Air Bersih)
BAKAS has been involved in supplying clean and treated water to rural areas since 1970.
Because there were some members of the community who cannot afford treated water supply,
in the early 1990’s the ministry of health along with the water supply authorities in each state
with the financial support from the Ministry of Rural and Federal Territories Development
provided quality water supply to these people.

Figure showing schematic water connection

Picture 4 Picture 5

Picture 4 & 5 shows the source of water supply before and picture 6 & 7 shows the water
supply provided by BAKAS in conjunction with Penang state water authority. To prevent
back-suction of contaminated water into the piping system, water tank is provided to each
house equipped with PBA system.

314
 Stand Meter with slab

Picture 6 Picture 7

Stand Meter with slab

Stand Meter with slab

connected to Water Tank

When water source cannot be availed from the water system or when source of water is from
underground and cannot be availed because of rocks underneath the ground and if water can
be sourced from the higher grounds then gravity feed system is created. A two-room water
system is built at the source, and a pipe is connected from the system to bring water to the
house. This system is properly enclosed to ensure that no contaminants enter into the water
system.

Malaysia being a tropical country has heavy rain fall during most months of the year. Thus
the rain water can be a source of water supply for domestic use. This system is used for
houses with non-corrosive roofs which have rain gutters which are attached to a water tank.
However this system is very susceptive to contamination.

315
Tube wells are used to access underground water from depths of 60 feet. These controlled
wells (Telaga Terkawal) ability to supply clean water depends largely on the soil type and the
water reservoir and electric generator used.

316
Sullage Water Disposal (Air Limbah)
‘Air Limbah’ is sullage water from domestic use such as bathing, washing, and laundry.
Management of used water disposal is the responsibility of BAKAS and the companies
elected by the state governments to treat sullage/used water. In areas bereft of proper
drainage system ‘air limbah’ flows onto the ground and becomes a source of pollutant where
flies and other microorganisms causing diseases thrive, and form a breeding site for
mosquitoes which serves as vector of diseases. In addition to this, the foul smell can also be a
nuisance. By proper disposal of the used water, the transmission of infectious diseases can be
controlled. Two methods of disposal of used water are used in housing areas with no or poor
channelling system of household waste (excluding human waste) - individual and integrated
type (sistem bersepadu). Both techniques have the same concept but differ in terms of the
how many houses are sharing the same system. This organized used water disposal can help
avoid clogging of drains due to household sewage and reduce breeding sites for vectors.

The figure below shows the individual type of used water management. The sewage water
from the kitchen sink and bathroom is connected to a pipe which leads the sewage water to
the SPAL* box. In the SPAL box, solids and mostly foodstuff are filtered. The filtered water
will then flow to the side of the house and the sewage water finally drains into the river
nearby. The filter must be cleaned every day otherwise the food will get stuck in the filter
causing the sewage water to overflow. This is only a temporary measure to treat sewage
water.
*SPAL is the Sistem Pelupusan Air Limbah which is Waste Water Disposal System

Main concrete River

House SPAL Concrete ring
ring

Figure showing the individual type of management of used water

Figure below shows the integrated type of used water management.

House SPAL

Main
Concrete ring concrete
ring /filter

House SPAL

River
317
House
Picture 8 showing SPAL system

Solid Waste Disposal (Pelupusan Sisa Pepejal)

Improper solid waste disposal can have an impact towards the public’s health, economy and
nature. It can cause the spread of infectious diseases and pollution of the underground water.
BAKAS provides three methods of disposing solid waste i.e. mini incinerator, solid waste
hole with lid and pole bin. Picture 9 & 10 shows improper waste disposal before BAKAS and
picture 11 of solid waste disposal after Bakas projects.

318
Picture 9 Picture 10

Picture 11 showing individual containers given to individual house owners

Applications are made to BAKAS by the interested individuals, landlord, head of village, the
Village Development and Security Committee (Jawatankuasa Kemajuan Keselamatan
Kampung (JKKK)), the State Legislative Assemblymen (Ahli Dewan Undangan Negeri),
District Officer or by the recommendation by the Public Health Assistant (Pembantu
Kesihatan Awam). The officer in charge will survey the individual's house and the
surrounding area. The project will be carried out if the criteria set by BAKAS are met i.e. the
applicant is eligible and the site is suitable for project to be carried out. A discussion is held
with the applicant concerning the date and method of construction, date for delivery of
construction materials to the locality and commitments and roles of the people involved in the
project.

319
An example of the large concrete cylinder used to store garbage. When the cylinder is full, the rubbish
is burn.

Communal waste disposal provided by the local authority.

Water Treatment Plant

Safe drinking water is the basic element of primary health care. The importance of safe
drinking water for health and development has been reflected in the outcomes of many
international policy forums e.g. Alma Ata, World Summit on Sustainable Development.
Water is vital for the human body, 70% of body weight is composed of water. Water
facilitates body functions, controls body temperature, and is a major constituent of blood.
Water is so vital that 10% alteration in body composition will result in health problems, and
20% will end in death. In Malaysia, rivers provide 97% of drinking water. Because the
sources of water contain high amount of bacteria, chemical products and unpleasant smell
and taste, the water has to be treated before a safety usage.

The main objective of a water treatment plants is the supply of water that is chemically and
bacteriologically safe for human consumption.

320
 Process
SCREENING

GRIT

AERIATION Oxygen from

atmosphere dissolved in
water

CHEMICAL COAGULATION and

addition of pre lime, pre chlorine and
PAC

SETTLEMENT flocs
settle down and
forming sludge
FOCCULATION
FILTRATION (fine
colloidal materials,
sand are filtered)
CHLORINATION

FLUORIDATION

CONDITIONING

Storage reservoir

Consumers (through
distribution pipeline)

Figure showing the Steps in water treatment

Raw water
Raw water is treated in the treatment plant to produce drinking water which confirms to the
quality set by the National Quality of Water Guidelines (1983) and Guidelines of World
Health Organization for water quality control. To reach the standard quality, the water has to
undergo several processes which involve physical, chemical and bacteriological treatment.
The first process of treating river water is screening. Raw water from the river is filtered to
trap or filter any large foreign materials such as leaves, garbage, tree branches, and animal
corpses. This is commonly done using a set of vertically arranged iron rods. This is followed
by filtration of inorganic materials, such as sand and mud through the sand suction system.
Water is then pumped to undergo aeration process.

321
Picture 12 Screening to trap large foreign matter

Aeration
This process reduces the unpleasant smell, taste and the soluble particle changes into
insoluble particles. During the aeration process, the oxygen from the atmosphere is dissolved
in water to remove odour and to refresh it. Metals in the raw water such as iron and
manganese are oxidised to insoluble particles to enable them to be removed.Carbon dioxide
and hydrogen sulphate are released into the air.

Picture 13 Aeration process Picture14 water is pumped into the aeration process

Chemical treatment
After the aeration process, 3 chemicals are added into the water, which are poly aluminium
chloride (PAC) or aluminium sulphate, pre lime and pre chlorine. Lime is used to control the
pH. The pH of the water is maintained between pH 7 to 9. Chlorine which is a disinfectant
and a purifier can kill bacteria, viruses, and prevent algae growth. PAC is used for the
flocculation process - reaction between aluminium and colloids and fine suspended particles
form flocculates.

322
 Picture 15 the pipes supplying the chemicals

Picture 16 addition of pre lime, pre chlorine and PAC

After the addition of chemicals, the water passes through a channel which is lined by a set of
planks (mixing tank). When the water hit the planks, it will create vortex causing a thorough
mix of water and the chemicals, especially PAC which will enhance the formation of flocs.

Picture 17 flocculation tank

323
Picture 18 flocs forming

The formed flocs will settle down in a sedimentation tank because of gravity. This is called
sludge, and will be removed from the water. This tank is cleaned at least once a month,
depending on the amount of sediment at the bottom of the water.

Picture 19 sedimentation tank

Water from sedimentation tank then flows into the filtration house. Here the water is filtered
through a bed of fine sand to remove fine suspended solids and colloidal material, usually
occurs by the force of gravity, to trap light colloidal materials that do not settle, fine foreign
particles, sands, and bacteria. There are few types of filtration, such as slow sand filter, rapid
sand filter and rapid pressure filter.

324
Picture 20 filter house

Chlorination
Some microorganism may still pass through the filtration process; hence the filtered water
needs to be disinfected to ensure the pathogenic organism is killed. The filtered water flows
to clear water tank, where gaseous or liquid chlorine as well as chlorine in its hypochlorite
form is commonly used. Lime and sodium silica fluoride are also added. Fluoride is
important in strengthening the teeth, especially in children. Calcium hydroxide is added to
increase the pH of the water because the water is acidified by PAC. Other than that, it also
protects the pipe, which is used to transport water, from becoming rusty.

Treated water is stored in a storage reservoir. This will allow all chemicals that have been
added to react completely. Water from this tank will then be channeled to a balancing tank to
be distributed to the consumers.

Picture 21 clear water tank

325
Picture 22 storage reservoir

Quality Control

The drinking water must be safe and free from harmful organisms, such as E. Coli and
Coliform, chemical substances, and radioactive agents which can threaten the health of the
consumers. The quality and safety of treated water in the water treatment plant is monitored
by the ‘Kawalan Mutu Air Minuman’ (KMAM)unit of the district health office. Physical and
chemical tests are performed every 2 hours and are recorded in a log book. This book will be
inspected by the health inspectors (Penolong Pegawai Kesihatan Persekitaran) from the
Ministry of Health. Microbiologic tests are done once a day to ensure pathogen free water. It
also monitors the quality of water according to MOH. The treated water quality and safety is
checked weekly by the district health department. The water is checked for

1. Physical and bacteriological: Turbidity, pH, residual Chlorine, E. coli

2. Inorganic/chemicals: Chloride, Ammonia, Nitrate, Iron, Manganese, Fluoride
3. Heavy metal: Mercury, Cyanide, Arsenic, Lead, Copper, Sodium, Sulphate,
chloroform
4. Biocides, pesticides, herbicides – DDT, Hexachlorobenzene, 2,4-D
5. Radioactivity

The water samples are taken at the designated sampling points using a standard operating
procedure to ensure that there is no contamination of the sample water which could lead to
false positive laboratory results. The sample water is transported in a special “cool box” filled
with ice cubes. The ice cubes are used to prevent the multiplication of the micro-organisms
(if any) in the water sample, which can lead to overestimation of their number in the treated

326
water. The results of all tests for the water sample are reported by the laboratory, and must be
reported within 30 days.

Malaysian standard for treated WHO standards

Parameters
water (mg/l)
Normal Turbidity Unit (NTU) <5 <5
Colour (TCU) <15 <15
Smell None None
Taste None None
Free chlorine (mg/L) 0.2-5.0 0.2
Aluminium (mg/L) ≤0.2 ≤0.2
Ferum (mg/L) <0.3 <0.3
Fluoride (mg/L) 0.4-06 <0.5
Nitrate (mg/L) <10 <10
Ammonia (mg/L) <1.5 <1.5
Manganese (mg/L) <0.1 <0.1
Calcium Carbonate (mg/L) <500 <500
Total Dissolved Solid <1000 <1000
Faecal Coliform None None
Total Coliform None None

Sewage Treatment

Sewage may mean raw sewage, sewage sludge or septic tank waste. As the population of the
world rises so does human waste. Indiscriminate disposal of human waste can threaten the
sources of fresh water supply with bacteria, oil, grease, chemicals like nitrate and sulphate.
Proper sewage management is needed to control the occurrence of infectious diseases like
cholera and typhoid. The principal objective of wastewater treatment is to allow human and
industrial wastes to be disposed of without danger to human health or unacceptable damage
to the natural environment. Basically sewage management involves the removal of large
floating materials, sedimentation of smaller materials, biodegradation of organic compounds
by bacteria and the removal of pathogenic organisms by chemical or physical treatment.

In Malaysia there are 2 main methods of sewage management; Individual Septic Tank and a

centralized Sewage Treatment Plant.

327
Individual Septic Tank

Pictures of individual septic tank

Individual septic tank is one of the simplest forms of sewage treatment. Individual septic
tanks are usually found within the vicinity of or buildings with PE* of less than 150. It has
two series of connected chambers. Sewage from the household would enter the first chamber.
In the first chamber, solids from the incoming influent settles at the bottom of the chamber to
form "sludge", while grease and oil float on the surface to form the "scum" layer. Sludge or
sediments on the floor of the chamber also contains pathogenic bacteria. Waste from between
the scum and sludge layers known as effluent then passes into the second chamber. Further
sedimentation will occur in the second chamber. The sludge in the tank is biodegraded by
anaerobic bacteria and is converted into a more stable organic compounds and gases such as
carbon dioxide (CO2), methane (CH4) and hydrogen sulphide (H2S). Finally, the effluent
leaves the second chamber and is discharged into a drain or allowed to penetrate into the soil.
The retention times for individual septic tanks are 24-hours. There should be adequate storage
capacity so that scum and sludge can be stored in the tank for up two years. The tank must be
dislodged to keep the tank functional. The waste from these tanks are only partially treated,
thus still rich in organic material. This has the potential to create health, environmental and
odour problems, particularly in urban areas.

*Population Equivalent (PE) is the measure of the usage of sewage facilities by the community. It is used to
determine the type of sewage management suitable for a particular community.

328
Sewage treatment plant
Sewage treatment plant is a centralized or common centre for the management of sewage
from housing estates, industries, or commercial buildings. Underground pipes are laid from
the building to the common infrastructure to allow flow of sewage.

Preliminary and primary treatment

This is the first stage of treatment and it is also sometimes called the physical unit operations.
Sewage from different vicinities flows through screens, where the larger materials which may
cause maintenance or operational problems to the treatment operations are removed. The
sewage then flows into a grit chamber, where heavy inorganic solids (e.g. sand particles)
form sludge and settle to the bottom. The remaining liquid, called effluent, is chlorinated to
kill the remaining bacteria and is released into a waterway or into secondary treatment. The
waste from primary treatment contains high amounts of organic matter because primary
treatment is only capable of removing half of the solids and bacteria and 30% of the organic
wastes from the raw sewage. Individual Septic Tanks, Communal Septic Tanks and Imhoff
Tanks are the examples of primary sewage treatment

Imhoff Tanks - Imhoff Tank is a type of primary sewage treatment which is used to service
small communities up to a population equivalent (PE) of 1,000. It comprises two chambers
positioned one above the other. In the upper compartment (sedimentation tank),
sedimentation occurs with heavier solids passing through an opening into the lower chamber
and the settled solids form sludge in the lower chamber and undergo anaerobic digestion.
Gases that are formed in the lower tanks flow out to the environment. Scum is accumulated
in the upper tank. Treated waste is collected and discharged into a nearby drain. This system
requires filtration through rock medium or soil absorption system. The system also needs
regular care to dispose sludge and to clean filter, and if care is not properly done, the tank
will become a breeding place for vector borne diseases.

Secondary sewage treatment

Because secondary sewage treatment removes biodegradable organic and suspended solids
using biological unit processes it is also sometimes referred to as biological unit processes.
Disinfection may be included in secondary sewage treatment. Secondary treatment is able to
dispose 85 to 90% of the solids and organic matter from the primary treatment. The most
common type of secondary sewage treatment in Malaysia is the Oxidation Pond. Oxidation
ponds represent 12% of all sewage treatment plants. Oxidation pond or stabilization pond is a
common sewage treatment process for small communities because of their low construction

329
 and operating costs. It is a pond which contains partially treated wastewater, which is left to
allow the growth of algae and bacteria which decompose the rest of the waste. Oxidation
ponds may comprise one or more shallow ponds in a series. The degree of treatment is
weather dependent. The natural surface aeration occurs and algae photosynthesis supplies the
oxygen. Bacteria present in the sewage water use the oxygen to feed on organic material and
breaking it down into nutrients and carbon dioxide. These will then be used by the algae to
support their growth. The growth will support further decomposition of the organic matter by
producing more oxygen. Other microbes in the pond such as protozoa remove additional
organic and nutrients to control the waste. Normally, at least two ponds are constructed.
Reduction of the organic material using aerobic digestion will occur in the first pond while
the second pond controls the waste and reduces the pathogens present in sewage. The effluent
is usually chlorinated during the tertiary treatment process and the effluent will then be
discharged into a drain. Oxidation ponds need to be dislodged periodically in order to work
effectively. Depending upon the design, the oxidation ponds must be dislodged
approximately every 10 years.

Recreation by Wind Action

Wind

Sunlight
Water Level

Treated Effluent
Algae

Aerobic Cycle

Oxygen Carbon Dioxide ,NH4 PO4

Bacteria

Raw Sewage Organic Matter

Bacteria
Anaerobic
Decomposition

Pond Bottom
330
Secondary sewage treatment
Tertiary Treatment
This is a final treatment stage done to purify the effluent. Tertiary sewage treatment includes
the removal of nutrients, and toxic substances like heavy metals and further removal of
suspended solids and organic. A type of tertiary treatment is chemical treatment, where
reactants namely chlorine is added to the effluent to destroy pathogenic organisms. Another is
the use of irradiation. Tertiary treatment is rarely done because a properly maintained plant
with primary and secondary treatment processes would produce effluent with Biological
Oxygen Demand of 20mg/l and SS of 30mg/l which is considered safe for release into the
stream. Waste from tertiary treatment is of a high standard and suitable for reuse.The sewage
systems that are being used in Malaysia consists of primary and secondary treatment.

Sewage Preliminary effluent

Primary Treatment Secondary Treatment Tertiary Treatment
inflow Treatment discharge

screening sedimentation activated sludge filtration

grit removal floatation Bio-filtration disinfection
grease tank sedimentation tertiary ponds
pre-aeration
flow measurement
flow balancing
biological and
removal of rags, removal of settle biological treatment to
chemical treatment
rubbish, grit, oil, able and floatable remove organic and
to remove nutrients
grease materials suspended solids
and pathogens

331
References
4th ASEAN & Japan High Level Officials Meeting on Caring Societies : Support to Vulnerable People in
Welfare and Medical Services, 28-31 August 2006

2008-2013 Medium action plan for global strategy for the prevention and control of NCD'S-WHO-
www.who.int/nmh/publications/9789241597418/en/index.html

A Case Study Leptospirosis in Malaysia Lim JK, Murugaiyah VA, Ramli A, Abdul Rahman H, Mohamed
N, Shamsudin N, Tan JC. A Case Study: Leptospirosis in Malaysia . WebmedCentral Infectious Diseases
2011;2(12):WMC002703.

A comparative evaluation of dengue diagnostic tests based on single acute serum samples from lab
confirmation of acute dengue.Chua KB,Mustafa B, Abdul Wahab AH,Chem YK,Khairul
AH,Kumarasamy V,Mariam M,Nurhasmimi H,Abdul Rashid K .Malays J Patho1,2011,Jun;33(1):13-
20.

A history of HIV/AIDS epidemic with emphasis on Africa — UNAIDS and WHO-

www.un.org/esa/population/publications/.../UNAIDS_WHOPaper2.pdf

AIDS/STD section under disease control division (MOH)-Annual report 2004

Aljunid, S, Zafar, A, Saperi, S, Amrizal, M, 2010. Burden of Disease Associated with Cervical Cancer in
Malaysia and Potential Costs and Consequences of HPV Vaccination. Asian Poe J Cancer Prey, 6, 1551-
9.
ONO, "II ......

Al-Dubai, SAR, Alshagga, MA, Al-Naggar, RA, Al-Jashmany, K, Baobaid MY, Tuang, CP, Abd Kadir,
SY, 2010. Knowledge, Attitudes and Barriers for Human Papilloma Virus (HPV) Vaccines among
Malaysian Women. Asian Pacific J Cancer Prey, 11, 887-892

Alex Preker & April Harding, Innovations in Health Care Deliver: Corporatization of the Public Sector.
Washington, DC: World Bank, 2002

Anil Metto. Malaysia: National Health Insurance can Marginalise Poor. Inter Press Service News
Agency, 2005. Online http://ipsnews.net/interna.asp?idnews=28866

Aniza M Jamsiah, SA Amin, M Ali, AM Munizam. The Malaysian health reform in primary health care
services. Journal of Community Health 2008;14(2):1-10

Annual Report. Ministry of Health 2007. MOH

Annual Report. Ministry of Health 2002. MOH

Arukesamy, K, 2009. Govt offers cervical cancer vaccine for girls from 2010. Sun Media Corporation,
[Online]. Available at: http://www.sun2surf.com/articlePrint.cfm?id=38371 [Accessed 06 May 2011].

Asia pacific community mental health project Malaysia country report —Dato Suaran Singh a/1 Jasmit
Singh- www.crc.gov.my/documents/msmreport 2007.pdf

Asia Pacific Strategy for Emerging Diseases (APSED) 2010 -

www.wpro.who.int/rcm/en/archives/rc61/rc.../wpr_rc61_r5.htm

332
Asian Food Regulations Information Service. Malaysia Agriculture/Agricultural Products- regulations and
standards. [online] available at

http://www.asianfoodreg.com/regulations standard.php?id=14&induid=4&indtvpe=S [accessed on

31 Oct. 12]
Australian online coastal information

Bryant JH. Education tomorrow's doctors. In World Health Forum. World Health Organization,
1993;217

Cawangan Penyakit Bawaan Vektor, KKM, edisi 2009-moh.gov.my

Cardiovascular disease ,risk factors-INTERHEART Risk Factors, Lancet, 2004 Sep 11-
17;364(9438):93752: Salim Yusuf, Steven Hawken, Stephanie Ounpuu, Tony Dans, Alvaro Avezum,
Fernando Lanas, Matthew McQueen, Andrzej Budaj, Prem Pais, John Varigos, Liu Lisheng.

CDC malaria

CDC sentinel surveillance method- http://www.cdc.gov/abcs/reports-

findings/downloads/sentinelmethod.pdf

Cervical Cancer Incidence and Mortality Rates. 2011. Cervical Cancer Incidence and Mortality Rates.
[ONLINE] Available at: http://appliedresearch.cancer.gov/icsn/cervical/mortality.html. [Accessed 05
May 2011]

CHAMEOPROPHYLAXIS MALARIA-Moh portal malaria case study done in Sabah

Chew BH, Fatanah I, Noridah MS, Ramli AS, Zil Falillah MS. Primary Care Services in
Malaysia. National Healthcare Establishments & Workforce Statistics 2008-2009

Chye, GLC, Yahaya, H, 2003. Second Report of the National Cancer Registry Cancer Incidence in
Malaysia. National Cancer Registry, Malaysia, [Online]. ISSN 1675-8870, 141. Available at:
http://www.crc.gov.my/documents/report/2nd%20National%20Cancer%20Registry.pdf [Accessed 06
May 2011].

Clinical practice guidelines for management of adult asthma-a joint venture by MalaysianThoracic
society, Ministry of Health and Academy of Medicine of Malaysia-

www.acadmed.org.my/view_file.cfm?fileid=220

Cosgrove MP, Sargeant LA, Griffin SJ. Does depression increase the risk of developing type 2
diabetes? Occup Med (Lond) 2008; 58: 7-14

Dato' Dr Mohan Singh. PPS Chairman. 1Care for 1Malaysia. Future of Primary Health Care.PPS column.
Malaysian Medical Association News March 2011

DENGUE- WHO DENGUE WESTERN PACIFIC REGION She FMT.

Dengue fever in Penang bmj.1902; 2:1581-2.

Department of Health, 2009. Informatics Planning 2010/11. Guidance, [Online]. 13221, 28. Available at:
http://www.dh.gov.ulden/Publicationsandstatistic s/Publications/PublicationsPolicyAndGuidance/DH
110 335

Dictionary of epidemiology- Definition of communicable disease

333
DOTS strategy India- the challenges,Prof V.K.Arora,Dr.Rajnish gupta CMJ-vol8 no .4:July 2002;P19-
27

Dr.Rohayah Abdullah FMS,PKK, Asthma Facts- www.moh.gov.my/attachments/4749

Economic Planning Unit. Prime Ministers Department. Malaysia: Achieving the millennium
development goals - successes and challenges. Kuala Lumpur UNDP 2005

Epidemiology of scrub typhus Epidemiology of scrub typhus ; Dinesh kumar, D.J.Raina

,Sanjana gupta,Ana Anugurana -
http://www.jkscience.org/archive/volume122/Epidemiology%20or/o20Scrub%20Typh
us3.pdf/

Fang R et al. The 1982 epidemic in Malaysia.Epidemiological,serological and virological

aspects.South East Asian J Trop Med Pub Hlth 1984;15:51

FAO/WHO. Food safety risk analysis. A guide for national food safety authorities. FAO food and
nutrition Paper 87. Food and Agriculture Organization, Rome. World Health Organization,
Geneva.

Free Dictionary by Farlex-Definition of communicable disease

Gallego G, Goodall S, Eastman CJ. Iodine deficiency in Australia: is iodine

supplementa- tion for pregnant and lactating women war- ranted? Med J Aust 2010; 192:
461-463

Giese-Davis J, Collie K, Rancourt KM, Neri E, Kraemer HC, Spiegel D. Decrease in depression
symptoms is associated with longer survival in patients with metastatic breast cancer: a secondary
analysis. J Gin Oncol 2011; 29: 413-20

Global prevalence of diabetes-WHO- www.who.int/diabetes/facts/en/diabcare0504.pdf

Gonzalez JS, Safren SA, Delahanty LM, Cagliero E, Wexler DJ, Meigs JB, et al., et al. Symptoms
of depression prospectively predict poorer self-care in patients with Type 2 diabetes. Diabet Med
2008; 25: 1102-7

Healthy Lifestyle Media Campaign & Smoking Cessation Media Campaign 2006/2007

HIV —AIDS 17 Surveillance epidemiological

monitoring-www.un.org/esa/population/publications/.../UNAIDS_WHOPaper2.pdf

HIV, Asia Pacific region- www.aidsdatahub.org/

HPP malaria guidelines 2010(2) (WHO malarial treatment guidelines

Hsu Dar Ren. Malaysian Healthcare. Where are We Heading? A critical look at the proposed
National Health Financial Scheme. http://hsudarren.files.wordpress.com/2006/10/malaysian-
healthcare-a-criticallook.pdf

http://www.wpro.who.int/entity/emerging_diseases/DengueSituationUpdates/

en/index.html Jan 2007 emerging infectious disease journal

334
JE who Global Alert and Response (GAR) 1999 epidemic encephalitis in Malaysia

J. M .Harrington.F. S. Gill (1992).Pocket Consultant. Occupational Health (3' 1 Ed.). Oxford

Blackwell Science

Kalaazar- http://www.searo.who.int/en/Section10/Section2163 16226.htm

Kamaliah MN, Teng CL, Nordin S, Noraziah AB, Salmiah MS, Zakiah MS, Fauzia AM,
Normimiroslina CO, Nadia FMG, Farah A, Mohd AY. Primary Care Establishments in Malaysia.
National Healthcare Establishments & Workforce Statistics 2008-2009

Kamaliah MN. Primary Health Care Reform in 1CARE for 1 Malaysia. International Journal of
Public Health Research Special Issue 2011;50-56

Koibuchi N, Chin WW. Thyroid hormone action and brain development. Trends Endocrinol
Metab 2000; 4: 123-128.

La Dou, J. (1990). Occupational Medicine. A Lange Medical Book. Norwork. California. Appleton
Range.

Laws of Malaysia. Act 281. Food Act 1983. The Commissioner of Law Revision, Malaysia. Under The
Authority of The Revision Of Laws Act 1968. In Collaboration with Percetakan Nasional Malaysia
Bhd. 2006.


Leptospirosis in the Asia Pacific region. BMC Infectious Diseases 2009, 9:147 Doi:10.1186/1471-2334-9-
147.Ben Adler Ann FB Victorianol, Lee D Smythe2, Nina Gloriani-Barzagal, Lolita L Cavintal, Takeshi
Kasai3, Khanchit Limpakarnjanarat4, Bee L Ong3, Gyanendra Gongal4, Julie Ha113, Caroline A
Coulombe3, Yasutake Yanagihara5, Shin-ichi Yoshida5 and Ben Adler

Lim TO, Sivasampu S, Nadia FMG, Ariza Z. Overview on Primary Care Services in Malaysia. National
Healthcare Establishments & Workforce Statistics 2008-2009

Mafauzy M. The problems and challenges of the aging population of Malaysia. Malaysian Journal of
Medical Sciences, 2000;7(1):1-3

Malaria -Eliminate malaria report

MALARIA STRATIFICATION whqlibidoc.who.inthrs/WHO_TRS_936_eng.DOCUMENT NAME

Report of the informal consulation on stratification for planning antimalarial action.Moscow,U.S.S.R
,1985.WHOMNF/CONS/WP/85.0

Malaysian cancer statistics — Data and figure Peninsular Malaysia 2006 -

http://www.makna.org.my/PDF/MalaysiaCancerStatistics.pdf

Malaysian dietary guidelines. Key message 13. Consume safe and clean foods and beverages Ministy of
health Malaysia. [online] available at https://www.google.com.my/#111=en&sclient=psy-
ab&q=food+regulations+malaysia+1985&oq=food+regulations+malaysia+1985&gs_1=hp.3..0i30j0i8j0i8i
7i30j0i8i30.129008.135979.3.136598.10.10.0.0.0.1.397.1144.8j0j1j1.10.0.1es%3B..0.0...1c.l.G61fh2Bcllo
&pbx=1&bav=on.2,orsgcs_pws_cps_qf.&fp=ff246ec5909ee035&bpc1=36601534&biw=1366&bih
=65 9

Malaysian dietary guidelines —National coordinating committee on food and nutrition- Ministry of health,
Malaysia- www.moh.gov.my/images/gallery/Garispanduan/diet/introduction.pdf

335
Malaysia mental health profile-Parameshvara deva .M Int Rev psychiatry 2004 feb-may 16(1) :167-76
Management of chronic obstructive disease- www.moh.gov.my/attachments/4750

MAPTB.org.my- http://maptb.org.my/ Massie MJ. Prevalence of depression in patients with cancer. J

Natl Cancer Inst Monogr 2004; 32: 57-71

Mazza M, Lotrionte M, Biondi-Zoccai G, Abbate A, Sheiban I, Romagnoli E. Selective serotonin reuptake

inhibitors provide significant lower re-hospitalization rates in patients recovering from acute coronary
syndromes: evidence from a meta-analysis. J Psychopharmacol 2010; 24: 1785-92

Medium Term Strategic Plan to Further Strengthen the Cardiovascular Diseases & Diabetes Prevention&
Control Program in Malaysia (2010-2014)

Ministry of Heath Malaysia. Malaysia's health 2006. Technical report of the director-general of heath
Malaysia. Ministry of health 2006. Putrajaya.

Ministry of Health Malaysia. Annual Report 2004, Ministry of Health

http ://blo gmoh.moh. gov.my/the-american-malaysian-chamber-o f-commerce- amcham%e2%80%99s-

luncheon-on-national-healthcare-financing-%e2%80%93-the-way- forward/

Ministry of Health Malaysia. Health Indicators: indicators for monitoring and evaluation of strategy
health for all. 2009. Health informatics centre planning and development unit Ministry of health Malaysia
http://www.moh.gov.my/v/duk

Ministry of Health Malaysia. Health Facts 2010. 2011. Health informatics centre planning and
development unit Ministry of health Malaysia h ://wwwov.m /v/duk

Ministry of Health Malaysia. Country health plan. 10th Malaysia plan 2011-2015 Planning and
development unit Ministry of Health Malaysia. Putrajaya

Ministry of Health Malaysia. My Health — Health Status of Malaysia 2005

Planning and Development Division, Ministry of Health Malaysia. 2006.

Ministry of Health Malaysia. Malaysia's Health 2004 : Malaysia National Health

Account. Planning and Development Division, Ministry of Health Malaysia.
2006.

Ministry Of Health Malaysia, 2005. Primary Health Care Division Annual Report, Putrajaya

Mohamad Tah Arif Editorial. The Malaysian health system of the future in the context of
globalisation. Jurnal Kesihatan Masyarakat Special Issue 2002

Mustafa K Anuar. 1Care: What ails Malaysia's health care system? 3 February 2012. Aliran

NSP NCD 2012-Ministry of health Malaysia- www.moh.gov.my/images/gallery/nspncd/NSPNCD.pdf

NSP —HIV/AIDS 2006-2010- www.aidsdatahub.org/...hiv/aids-2006-2010-ministry-of-health-

malaysia2006

NSP —HIV AIDS 2011-2015- www.moh.gov.my/images/gallery/Report/NSP AIDS 2011 2015.pdf

OECD (2011), Higher Education in Regional and City Development: State of Penang, Malaysia
2011,0ECD Publishing. http://dx.doi.org/10.1787/9789264089457-en

336
Outline for a Study Group on World Health and the Survival of the Human Race. Material drawn from
articles and speeches by Brock Chisholm. Geneva: World Health Organization; 1954. Available from:
whqlibdoc.who.int/hist/.../ChisholmBrock 1953 Compilation.pdf

Parameswaran N. Hemorrhagic fever of children in Penang.Med.J.Malaya 1965;19:254-258.)

PLHIV-Malaysia-www.aidsdatahub.org/.../malaysia.../71-people-living-with-hiv-plhiv

Population and housing census, Malaysia 2010. (2010 Census) Population distribution and basic
demographic characteristic report 2010.

Primary Care Doctors' Organisatiom Malaysia (1998). A Citizens' Health Manifesto for
Malaysia. Aliran. Penang, Malaysia

Puteh, SEW, Ng, P, Aljunid, S, 2008. Economic burden of cervical cancer in Malaysia. Med J Indones,
17, 272-80

RudnickA ,Tan EE,Lucas JK,Omar M.Mosquito borne hemorrhagic fever in Malaya.bmj.1965;1:1269-

72

Reemergence of Endemic Chikungunya, Malaysia Sazaly AbuBakar*Comments to Author , I-Ching

Sam*, Pooi-Fong Wong*, Poh-Sim Hooi*, Nuruliza Roslan*, and NorAziyah MatRahim Jan 2007
emerging infectious disease journal

Recommended Nutrient Intake. 2005. Ministry of Health Malaysia.

http://www.who.int/occupational health/about/en/index.html

ei
Roslan J. Tahir A. & Nazir P.M. 2005. Patient Satisfaction in Public Hospitals, Quality in Health Section,
Medical Development Division, Ministry of Health Malaysia 1

Rugayah Hj. Bakri. Rozita Halina Tun Hussein. Sondi Sararaks. Azman Abu Baku. Tiew Chin Tong. Hj.
Lailanoor Hj. Ibrahim. Ang Eng Hye. Nor Suzila Hj. Salleh. ENHR: An Essential Link To Equity In
Development. Country Report Malaysia. Institute of Public Health Ministry of Health Malaysia 1999-
2000

Rugulies R. Depression as a predictor for coronary heart disease. a review and meta-
analysis. Am J Prey Med 2002; 23: 51-61
SEATCA- Resource Center of the Southeast Asia Tobacco Control Alliance-
resources.seatca.orWAbout%20SEATCA_Catalyst%20for%20Change.pdf

Shepard DS. Savedoff W. Phua Kai Hong. Health care reform initiatives in Malaysia. Report of a
consultation with the Planning and Development Division Ministry of Health, Malaysia. Schneider
Institute for Health Policy Heller School Brandeis University USA. 2002

Smoking Cessation Info line Yearly Report 2009

Steve Chia. Transforming Malaysian healthcare. October 7,2010 The Star online

The Edinburgh Declaration In Proceedings of the World Conference on Medical Education: 1998,
Edinburgh. World Medical Association; 1998

337
The Dengue Strategic Plan for the Asia Pacific Region (2008-2015)-
www.searo.who.int/entity/vector_borne_tropical.../index.html

The Ninth Malaysia Plan (2006-2010) -

www.who.int/countryfocus/cooperation_strategy/ccsbrief
mys_en.pdf

Tuberculosis in Malaysia: problems and prospect of treatment and control. Iyawoo K.Institute of
Respiratory Medicine, Hospital Besar, Kuala Lumpur, Malaysia.

UNITE Dengue (United In Tackling Epidemic Dengue)-www.unitedengue.org/manual/Userguide

UNITEDengue ver1.0.pdf

Wallace Hazel G,et al. Dengue haemorrhagic fever in Malaysia.1973 epidemic.South East Asian J
Trop Med Pub Hlth 1980;11:1-12.)

Vector Borne Disease Control Unit, Ministry of Health, Third Vector Technical Meeting 2009

Wan Nazaimoon, WM and Rusidah, S., 2010. "Malaysia needs wider coverage with iodized salt," IDD
Newsletter, February, pp.8-9

Whang W, Shimbo D, Kronish IM, Duvall WL, Julien H, Iyer P, et al., et al. Depressive symptoms
and all-cause mortality in unstable angina pectoris (from the Coronary Psychosocial Evaluation
Studies [COPES]). Am J Cardiol 2010; 106: 1104-7

World Bank report 2012- TB - data.worldbank.org/indicator/SH.TBS.INCD

World Development Report 1993: Investing in Health. Washington, DC: World Bank and Oxford
University Press, 1993

World Health Organization, United Nations Children's Fund, and International Council for the
Control of Iodine Deficiency Disorders. Assessment of iodine deficiency disorders and monitoring
their elimination. A guide for pro- gramme managers. 3rd ed. Geneva, Switzer- land: WHO,
2007.

World Health Organization, South-East Asia Regional Office: Communicable diseases; Kala-azar status
in SAE Region (online) 2005. Available at: http://www.searo.who.int/en/
Section10/Section2163.htm, accessed on July 19, 2010.

World Health Organization, 2006. Comprehensive Cervical Cancer Control: A Guide to Essential
Practice. Edition. World Health Organization.

World Health Organisation, health topics section Topic:Filariasis available as http://www.who. filaria .org

World Health Organization Topic: Plague available at http://www.who.int/topics/plague/en/

World Health Organisation Rationale for Yellow fever vaccination recommendation fact sheet
available at http://www.who.int/mediacentre/factsheets/fs100/en/

WHO Millennium development goals for tuberculosis-

www.who.int/topics/millennium
developmentgoals/.../index.html

338
Wong, LP, Sam, IC, 2010. Ethnically diverse female university students' knowledge and attitudes
toward human papillomavirus (HPV), HPV vaccination and cervical cancer. . Eur J
ObstetGynecolReprod Biol, 148, 90-5.

WHO (2006). Country Report on Malaysia. World Health Organisation. online

http://www.who.int/countries/mys/en

WHO Country cooperation strategy at a glance Malaysia-www.who.int/country focus/cooperation

strategy/ccsbrief mys_en.pdf

WHO.Expert committeeon malaria.17th report .Technical report series 640.1979,WORLD HEALTH

ORGANISATION,Geneva,Switzerland

WHO. filaria .org

WHO Global Burden of disease (GBD) -DALY 2004 Malaysia- www.who.int/evidence/bod Who plague

WHO Smoking cessation -http://www.who.int/tobacco/research/cessation/en/index.html WHO

Tuberculosis country profiles -http://www.who.int/tb/en/

WHO, UNICEF. & ICCIDD, 2007. Assessment of iodine deficiency disorders and monitoring their
elimination. 3rd Ed. Geneva: World Health Organization

WHO yellow fever

WHO. Regional office for South East Asia. Frequently Asked Questions. Scrub typhus. Scrub typhus-
http://www.searo.who.int/LinkFiles/CDS fag Scrub Typhus.pdf aw

www.unitedengue.org- http://phconference.org/pdf/1 st%2OSIPHC%20&%207th%2OPHOM%20-

%20%20ABSTRACTS/ORAL%20FREE%20PAPER%20PRESENTATION/05-
%201nfectious%20Disease/0-19%20DAVID%2OLEE.pdf.

www.hivinfosource.org/

Zenz. C. (1994). Occupational Medicine (3'l Ed.). Chicago Mosby Year Book Medical Publishers

339