Taklimat Program Pencegahan Dan

Kawalan Diabetis Kebangsaan

Kursus Update Diabetis Negeri
Johor
14/7-16/7/06
Di Hotel Sri Malaysia, Mersing, Johor

Oleh
Dr Abdul Rahim Bin Abdullah
Ketua penolong Pengarah, Unit kawalan Penyakit
Tidak berjangkit(NCD)
Jabatan Kesihatan Negeri Johor
Is NCD (CVD, DM) an important health
problem ?

Disease Burdens :
c
Global & Local

How serious is the problem ?

 Death, by broad cause group in year 2000
Total deaths: 55,694,000

Noncommunicable
Injuries (9.1%)
conditions (59.0%)

Communicable diseases, maternal

and perinatal conditions and
nutritional deficiencies (31.9%)
Source: WHO, World Health Report 2001
 The Global Death due to
Chronic Diseases (NCD)

 ~60% of the 56.5 million total reported

deaths in the world (2001)
• CVD -16.6 millions : 7 million CHD, 4.5 millions Stroke
• DM with complication- 4 millions
• COPD -2.7 millions

 Expected to increase to ~70% by 2020

 Developing countries:
• 71% - IHD
• 75% - stroke
• 70% - diabetes
The world health report 2002: reducing risk, promoting healthy life.
Geneva, World Health Organization,2002
 The World Health is in
Transition
Epidemiological: NCD overriding CD, & double
burden of diseases in many
developing countries
Demographic: Population ageing

Lifestyles: Diets are rapidly changing

Physical activity reducing
Tobacco use increasing
Urbanization: Growing cities
Globalisation: Increasing global influences
 The Malaysia Health is in
Transition
Epidemiological: NCD overriding CD, &
double burden of diseases

Demographic: Population ageing :

Increasing life expectancy

Lifestyles: Diets are rapidly changing

- High fat, low fiber, high salt
Physical activity reducing
Tobacco use increasing
Alcoholic
Urbanization: Growing cities : pollution
Globalisation: Increasing global influences
increased trade- foodstuffs, tobacco
 NCD
THE LOCAL SITUATION
The NCD Crisis (EPIDEMIC)
- Death
- Disease
- Risk Factors
 MALAYSIA

 NCD is leading in the 10 leading

causes of morbidity and mortality for
the last few years.

 Double burdens in term of disease

pattern: Preexisting infectious
diseases and emerging of NCD
problem.
 10 Leading Causes of Death in Government Hospital, 2000
Sebab Bil.kematian %
Heart Disease and Disease of Pulmonary Circulation 4779 15.76
Septicemia 4167 13.74
Malignant Neoplasm 2832 9.34
Cerebrovascular Diseases 2811 9.27
Injury (Accident) 2404 7.93
Certain conditions originating in the perinatal period 1811 5.97

Disease of Digestive System 1425 4.70

Pneumonia 1422 4.69
Nephritis, Nephrotic Syndrome, Nephrosis 1125 3.71
(glomerular diseases)
Ill-defined conditions 785 2.59

Sumber : IDS-Kementerian Kesihatan Malaysia 2002

 Projection of Risk Factor Burden

Disease 1996 2002 2006 2010 2020

Burden NHMS2

HPT 2,190,504 3,476,435 4,383,450 5,226,300 8,126,100

(29.9%) (39.5%) (45.9%) (52.3%) (68.3%)

DM 608,000 836,200 983,650 1,109,200 1,558,600

(8.3%) (9.5%) (10.3%) (11.1%) (13.1%)

Note: Based on NHMS2 1996. Prevalence rate increase proportionately.

 Projection of Risk Factor Burden
Burden of Risk Prev 1996 2002 2006 2010 2020
Factor

Smoking 24.8% 1,816,900 2,182,700 2,368,400 2,478,30 2,950,600

0

Obesity 4.6% 322,348 387,248 420,200 459,700 547,300

Overweight 16.6% 1,216,326 1,460,982 1,585,300 1,658,80 1,957,000

0

Physical 88.4 6,476,30 7,780,20 8,442,20 8,853,70 10,597,00

Inactivity % 0 0 0 0 0

IGT 4.3% 315,022 378,447 410,650 429,700 511,600

Alcohol 23%

Note: Based on NHMS2 1996. Prevalance rate remain constant.

Disease Burden= Pi x [p0 + (pi x Td)]
 Figure 2 : Risk Factors of Chronic Disease

12
10
Cases Millions

8
6
4
2
0
1996 2002 2006 2010 2020
Year
Smoking Obesity Overweight
Physical Inactivity IGT Alcohol
Note: Based on NHMS2 1996. Prevalance rate remain constant.
Disease Burden= Pi x [p0 + (pi x Td)]
 NCD
THE LOCAL SITUATION

8++ millions- adults

have at least 1 NCD Risk
Factors (modifiable)
Number of Diabetes Cases in
Health Clinics (2000 – 2002)

657958

525858
446847

Year 2000 Year 2001 Year 2002

 MANAGEMENT ISSUE
Control Status by HbA1c in Government
Facilities, 2002 - 2003
70000
58603
60000
48833
50000 60 -70 %
38180
40000 33035 poorly controlled
30000
17122
20000
11032
10000
0
2002 2003 2004

Total HbA1c Abnormal HbA1c

Source: Disease Control Division, MOH

 Di Negeri Johor

 DM
 Hypertensive dis
BILANGAN KES DIABETIS MENGIKUT DAERAH
TAHUN 2005

MER 924

PON 5715

SGT 5566

KT 7153

KLG 4620

MUAR 7299

BP 15623

JB 30213

0 5000 10000 15000 20000 25000 30000 35000

 PREVALEN KES DIABETIS (SETIAP 1000
PENDUDUK)
>35 TAHUN MENGIKUT DAERAH TAHUN 2005
MER 44
PON 166
SGT 103
KT 107
KLG 56
MUAR 71
BP 144
JB 75

0 50 100 150 200

 KES BARU DM & KOMPLIKASI DI NEGERI
JOHOR TAHUN 2003 - 2005

TAHUN BIL BIL KES BARU DENGAN KOMPLIKASI

KES
BARU
TIADA FOOT NEPHR NEURO RETIN URIN
ULSER O O MICRO

2003 4507 3822 321 59 46 66 193

(84%) (7.1) (1.3%) (1%) (1.5%) (4.2%)

2004 4281 3695 291 30 58 56 187

(85%) (6.8%) (0.7%) (1.35%) (1.3%) (4.3%)

2005 4791 4395 178 38 44 35 100

(92%) (3.7%) (0.8%) (0.9%) (0.7%) (2%)
 SARINGAN DM DAN KEPUTUSAN
RBS DI NEGERI JOHOR TAHUN 2003
- 2005
80000
70000
60000
50000
40000
30000
20000
10000
0
2003 % 2004 % 2005 %
NORMAL 35597 67.4 42104 76.8 68759 78.9
BORDER LINE 11224 21.3 8895 16.2 13680 15.7
DIABETIS 5981 11.3 3805 6.9 4757 5.5
 PENGENDALIAN KES IGT DI NEGERI
JOHOR TAHUN 2005

6355, 46%

KES DIRUJUK

KES X DIRUJUK

7465, 54%

24% DARIPADA KES YANG DIRUJUK DIBUAT

INTERVENSI
UJIAN HbA 1/c PESAKIT DIABETIS DI NEGERI
JOHOR TAHUN 2003 - 2005

12000
9034 9287 9796
10000
7904
8000
5642 ≤ 7%
6000
3004
≥ 7%
4000

2000

0
2003 2004 2005
 BIL SARINGAN RETINOPATHY PESAKIT
DIABETIS MENGIKUT DAERAH DINEGERI
TAHUN 2005
DAERAH BIL KES F CAMERA F COPY JUM PERATUS

JB 30213 662 0 662 2.0

BP 15623 0 1168 1168 7.5
MUAR 7299 0 825 825 11.3

KLG 4620 0 0 0 0
KT 7153 0 0 0 0
SGT 5566 0 0 0 0
PON 5715 0 0 0 0
MER 924 O 118 118 12.7
JUM 77113 662 2133 2755 3.5
UJIAN FUNDUSKOPI / FUNDUSKAMERA

272. 9%

2592. 91%
NORMAL ABNORMAL
BILANGAN KES HYPENTENSI DIKESAN
DI NEGERI JOHOR TAHUN 2003 - 2005

6500
6265
5999
6000
5310
5500

5000

4500
2003 2004 2005
 BIL PESAKIT DISARING UNTUK RISIKO
PENYAKIT KARDIOVASKULAR TAHUN 2003 -
3004

50000 47414
37435
40000

30000
20604
20000

10000

0
2003 2004
2005
 PERATUS KES DGN FAKTOR RISIKO
PENYAKIT KARDIOVASKURAL DIKESAN
DI NEGERI JOHOR TAHUN 2005
BIL DISARING 47,414 ORANG

14
12
10
8
6
4
2
0
BP > 140 / 90 PEROKOK BMI 25 - 30 BMI >30 CHOLESTROL > DIABETIS
5.2 MMO/L
BIL PESAKIT DISARING DENGAN BIL
FAKTOR RISIKO PENYAKIT
KARDIOVASKLAR DI NEGERI JOHOR
TAHUN 2005
FAKTOR RISIKO PERATUS

DGN 1 FR 20.9
DGN 2 FR 9.0

DGN 3 FR 7.7

DGN 4 FR 4.2
DGN 5 FR 1.2

JUMLAH PESAKIT DISARING - 47414

PERATUS BIL PESAKIT DISARING DENGAN BIL
FAKTOR RISIKO PENYAKIT KARDIOVASKULAR
DI NEGERI JOHOR TAHUN 2005
25
21
20

15

9 8
10

5 4

0 1

1 FR 2 FR
3 FR 4 FR
5 FR
BILANGAN KES CVA DI NEGERI JOHOR
TAHUN 2003 - 2005

2000
1632
1500
960 712
1000

500

0
2003 2004
2005
 Should We Attempt To Prevent
NCD(DM/CVD) ?
 Is NCD an important health problem ?
 Is NCD natural history established ?
 Is early detection test for NCD

available ?
 Has effective intervention for NCD been
developed ?
 Is NCD program cost effective?
 Should We Attempt To Prevent
A Chronic Disease (NCD) ?
 An Important health problem
 Natural history is established
 Early detection test available
 Effective intervention
 Cost effective program
 RISK FACTORS:
Determinants of NCD(DM/CVD)
BEHAVIORAL
BEHAVIORAL
 Tobacco
 Tobacco
 Diet
 Diet
 Physical
 Physical
Activity
Activity
 Alcohol
 Alcohol
END-POINTS
ENVIRONMENTAL
ENVIRONMENTAL INTERMEDIATE
INTERMEDIATE END-POINTS
Ischemic Heart
 Socio-cultural
 Socio-cultural
Dis.Ischemic Heart
RISK
RISK FACTORS
FACTORS 
 Policy
 Policy Hypertension
Hypertension Dis.
Stroke
 Economic
 Economic Diabetes
Blood lipids Stroke
Peripheral Vasc.
Dis.Peripheral Vasc.
 Physical
 Physical Obesity
Diabetes 
NON-MODIFIABLE
NON-MODIFIABLE Blood lipids Dis.
Obesity Cancer
 Age,
 Age, Sex,
Sex, Chronic Lung Dis.
Genes
Genes
 Health Spectrum

Healthy individual Exposure to risk

Early disease

Established Disease

Complication of Disease

Death
 Disease Spectrum

k k ns se et
ris ris s i g
toms ea n s
Lo
w At a rly m p Dis s t O
e a th
E Sy Po D

CHRONIC DISEASE (NCD)

 3 Categories of Client

Healthy At Risk Disease

Promotive Clinical preventive Clinical Curative

CLINICAL INTERVENTION
 LEVELS OF PREVENTION

Healthy individual Risk factors & Established Complication

Early Disease Disease
Health Specific Disability Rehab
Promotion Protection Screening Early Detections
& App Rx

Primary Prevention Secondary Prevention Tertiary Prevention

 Natural History disease and Hierarchy of Action

Under the scope of Hospital care and

Clinical specialist Severe Apparent
follow up form diseases
Primary care Mild
Mildform
Under the scope of
public health Physician form

Secondary
Remove causes prevention Unapparent
and risk diseases
Eradicate Primary
Eliminate prevention Pathogenesis started
Reduce burden Pathogenesis
ExposureOccur
Control
Early detection Availability of disease determinants
Program Pencegahan Dan
Kawalan Penyakit Tidak
Berjangkit
www.who.int/chp
 Ninth MP - Consolidation
Primary Goals
 Prevent and Reduce Disease Burden
 Enhance Health Care Delivery

Supporting Goals
 Optimisation of Resources
 Enhance Research
 Manage Crisis and Disasters
 Strengthen Health Information MS
 NCDs
1. NCDs Prevention & Control Programs
 Diabetes mellitus
 CVD (CVD, Hypertension & stroke)
 Cancer
 Tobacco

Violence & Injury Prevention

Substance & alcohol abuse

Blindness Prevention & Control Program
 Chronic Diseases and Clinical Preventive
Services
 NCD Surveillance
2. Environmental Health
3. Occupational Health
NCD Prevention & Control Program
GENERALl OBJECTIVES
 To reduce morbidity and premature
mortality of NCD

 To reduce NCD modifiable risk factors

such as hypertension, smoking,
hypercholesterolemia, diabetes mellitus,
obesity and physical inactivity in the
community.

 To improve the quality of life of people with

NCD
NCD Prevention & Control Program
STRATEGY

Healthy population Health promotion

High risk Clinical Preventive

groups/individuals Services
People with disease Clinical management
 HEALTH PROMOTION
 Incorporate into Healthy Lifestyle
campaigns
- adopt healthy lifestyle
- good nutrition
- weight reduction
- increase physical activity
 NCD Prevention & Control Program
CLINICAL PREVENTIVE
SERVICES
Target: High risk population

Activities :
 Identifying high risk individual:

CVD screening programme

Health Status Surveillance (My HeSS)

 Appropriate management of the risk factors- GLOBAL

RISK MANAGEMENT
 NCD Prevention & Control Program
Principle of Management for Chronic NCDs

1. Screen Screening programme

2. Register Registry

3. Clinical management CPG

4. Defaulter Defaulter tracing

5. Outcome monitoring Record & monitoring,

QA & Audit
 IMPLEMENTATION POLICIES AT VARIOUS
SERVICE LEVEL

1. Self and Community level

2. Community Nurse in Klinik Desa
3. HC with Medical Assistant ( without Medical
Officer)
4. HC with Medical Officer
5. HC with Family Medicine Specialist
6. Hospitals without Specialist
7. Hospitals with General Specialist
8. Hospitals with Sub-Specialties
 DIABETES
PREVENTION
AND CONTROL
PROGRAME
 Problem Statement:

1. Increasing burden of
Diabetes
2. Unsatisfactory clinical
management of
Diabetes
 GOAL

To improve the health status

of population through the
effective prevention and
control of Diabetes Mellitus
 GENERAL OBJECTIVES
1. To reduce the prevalence of
Diabetes
2. To detect early , to prevent and
minimize complication
3. To promote the adoption of
healthy lifestyles which can reduce
the risk.
4. To maintain the health and quality
of life of individuals with diabetes
through effective and continuous
patient care and education
 Problem Statement:
 Diabetic registry and reten
Equipment
 Staffing
 Budget
 Focus For 2006
 Diabetes Clinic Models

Capacity Building
 Diabetes Registry
 Supportive Services

(as part of Diabetes Clinic)

 Client Flow at NCD/DM Clinics

Registration

-Physical
Basic assessment -Biochemical
-Medical history

Consultation

Medication Life Diet/tobacco Footcare

counseling style/Exercise counseling counseling
counseling

INTERVENTION
-Behaviour
- Pharmacotherapy
 MODEL KLINIK DIABETIS
 DIABETIC TEAM.
 DIABETIC SCREENING.
 DIABETIC REGISTRY.
 DEDICATED DIABETIC CLINIC.
 DIABETIC CLASS/EDUCATION.
 COUNSELLING.
 DEFAULTER TRACING/HOME VISIT.
 HEALTHY LIFE STYLE/EXERCISE CLASS.
 RINGKASAN POA KAW DIABETIS 2006
STRATEGI AKTIVITI TINDAKAN

MENINGKATKAN 1.PENETAPAN SOP DAERAH KPP NCD FEB 06

KOMITTMEN MOH 2.PENETAPAN SOP KK/KD PKD
DAN ANGGOTA 3.KAJIAN SEMULA SOP KPP NCD MEI 06

MENENTUKAN 100% 1.LATIHAN ANGGOTA- 2 KPP NCD A-APRIL 7 MEI

PP & K DAN KALI/TAHUN 06
PARAMEDIK BERTERUSAN
DILATIH 2.ECHO TRAINING- 2 KALI/TAHUN PKD

1.MENINGKATKAN 1. MENSYUARAT JAK TEKNIKAL JKNJ//PKD APRIL & OKT

PENGURUSAN NEGER/DAERAH– 2 X/TAHUN
DIABETIIS 2. PENYELIAAN –NCD NEGERI- KPP NCDI JADUAL
2KALI/SEBULAN
3.MESYUARAT BERSAMA MA U32 KPP NCD APRIL, & OKT
DAERAH 2 KALI/TAHUN
4..KAJIAN QAP-100% KK- < DIS

PKD JUN-OKT
2.MENGEUJUDKAN 1.PEMANTAUAN BULANAN
KPP /MOH MULAI APRI
“MODEL KLINIK
DIABETIS” DI SETIAP
KLINIK KESIHATAN
 RINGKASAN POA KAW DIABETIS 2006

STRATEGI AKTIVITI TINDAKAN

MENDAPATAKN 1.PER ABM 2007 JKNJ

“DEDICATED 2.REDEPLOYMENT DARI UNIT JKNJ/PKD APRIL 06
DIABETIC NURSE” MCH
SETIAP KK 3.LATIHAN POS BASIK- LATIHAN PKD MEI-JUN
KHAS-FMS

MENINGKATKAN 1. MENGADAKAN KKM/JKNJ/ JUN

PENGURUSAN STANDARD REGISTRI PKD
DAFTAR/ RETEN 2.MESYUARAT BERSAMA MA APRIL &
REKOD U32 DAERAH 2 KALI/TAHUN OKT
Klinik Diabetis
Contoh perisian Sistem Maklumat
Pesakit Diabetis
– PKD Pontian
 MODEL KLINIK DIABETIS
KK BANDAR MAS, KOTA TINGGI

1. KELAS DIABETIS
2. J – ROBIK
3. LATIHAN ANGGOTA
Program Kecergasan Ibu-
Pejabat 2002
Senamrobik di Tasik Perdana
Sabtu minggu ke-4
 Intervention:
Physical Exercise
Malaysia Fitballrobic & Jump Rope
Competition 2003

Kuantan Pahang
 Intervention
Health Clinic:

 Hypertension clinic
 Diabetes clinic
 NCD clinic (2005)

Hospital
Prevention: 20 30
Appropriate facilities and equipments


Clinic Resource Center
• At district/clinics
• Manpower, machine,
materials &
management
MODEL KLINIK BERHENTI MEROKOK –
KK KAYU ARA PASONG PONTIAN
ALAT PENGESAN ASAP ROKOK
 PENCAPAIAN KLINIK BERHENTI
MEROKOK KK Kayu Ara Pasong
Pontian
AKTIVITI 2000 2001 2 2003 2004 2005
002

DAFTAR 24 66 54 46 54 62

RAWATAN 22 63 53 43 54 58

BERJAYA 8 8 11 10 10 23
BERHENTI
Program Obesiti KK Beserah
29 Jan- 27July 2005
Anjuran Bersama Panel Penasihat
TERIMA KASIH