plenary 3-kuantan fms sesi mdg 0800 060713

BATTLE AGAINST HIV/AIDS, MALARIA & TB

ARE WE WINNING?

BY

SHAARI NGADIMAN,

MD, MPH, EIP, AM

MINISTRY OF HEALTH MALAYSIA

[email protected]

HIV/AIDS kill > 20 millions 90% Malaria death in Africa TB death about 1.8 millions TB/HIV death about 0.5 million

Evolution of the Millennium Development Goals

World leaders at the United Nations Millennium Summit held in New York in September 2000 resolved to strengthen global efforts for peace, democracy, good governance, and poverty eradication while continuing to promote the principles of human rights and human dignity.

The Millennium Declaration made a strong commitment to the right to development, to gender equality and the empowerment of women, to the eradication of the many dimensions of poverty, and to sustainable human development.

The Millennium Development Goals (MDGs) emerged as the principal means of implementing the Declaration.

In September 2000, 189 world leaders including Malaysia adopted the Millennium Declaration which was translated into a set of eight Millennium Development Goals

The goals have been commonly accepted as framework for measuring development progress. In September 2005, the UN Summit resoundingly endorsed these MDGs.

These goals are set for the target year of 2015 with 1990 as the baseline and are summarized on issues that afflict developing countries like ours.

Evolution of the Millennium Development Goals

Millennium Development Goals 8 goals

MDG 1 - to eradicate extreme poverty and hunger.

MDG 2 - to ensure all boys and girls complete a full course of primary schooling, in other words universal primary education.

MDG 3 - relates to the status of women, by promoting gender equality and empowerment of women.

MDG 4 - to reduce child mortality.

MDG 5 - to improve maternal health.

MDG 6 - to combat HIV/AIDS, malaria and other diseases.

MDG 7 - to ensure environmental sustainability, and the measures relate to safe drinking water and slum dwellers.

MDG 8 - to develop a global partnership for development. Many of these relate to trade and financing systems that will benefit countries those saddled with debts.

TARGETS AND INDICATORS

MDG Target Indicators

6a Have halted by 2015

and begun to reverse the

spread of HIV/AIDS

Prevalence among 15 24 years Condom use at last high risk sex Proportion with comprehensive correct

knowledge

Ratio of school attendance of orphans

6b Achieve universal access

to treatment for

HIV/AIDS for all who

need it by 2010

Proportion of infected persons (advanced HIV) with access to ART

6c Have halted and begun

to reverse the incidence

of malaria and other

major diseases by 2015

Incidence and death rates Insecticide-treated bed nets Appropriate anti-malarial drugs (fever) TB incidence, prevalence and death rates Detection and cure rates (DOTS)


ARE WE WINNING?

PART 1

HIV / AIDS

SYNOPSIS GLOBAL SITUATION

Target of NSP on AIDS 2011-15

80% MARPs reached prevention programmes

60% of MARPs use condoms consistently.

60% of IDUs use clean injecting equipment.

Able to eliminate vertical HIV transmission

80% ARV coverage for eligible PLHIV,

HIV NOTIFICATION IN MALAYSIA

0

0.5

1

1.5

2

0

500,000

1,000,000

1,500,000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Detec

tion r

ate (%

)

No. sc

reenin

g

Year

No. screening Detection Rate

Cumulative HIV = 98,279

Cumulative deaths = 15,688

PLHIV (end of 2012) = 82,591

Annual Notification of HIV/AIDS and HIV&AIDS Death , Malaysia 1986 - 2012

No. of Annual HIV Testing and Positive Rate

NEW HIV CASE: TARGET FOR 2015

YEAR

2008 2009 2010 2011 2012 2013 2014 2015

TARGET 16.0 15.3 14.6 13.9 13.2 12.5 11.7 11.0

ACHIEVED 13.3 10.8 12.8 12.2 11.7

Target : To reduce new HIV from 21.7 per 100.000 pop (year 2000) to 11 per 100,000 pop by year 2015

TB-HIV CO-INFECTION IN MALAYSIA

Isoniazid Prophylaxis Therapy in 2010

MALAYSIA HIV SITUATION

0

10

20

30

40

50

60

70

80

90

100

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012

Perc

en

tag

e o

f H

IV c

ases

IDU Sexual

MALAYSIA HIV SITUATION

Estimated Prevalence of Selected Groups EPP Model 2013

COVERED (2012):

PROGRAMME:

(REGISTERED CLIENTS)

NSEP (55,255) MMT (27,756)

Retention Rate 70.1 (2012)

PRIVATE GPs

DST (22,000)

Estimated PWID : 170,000 Coverage about : 62%

CUMMULATIVE ON HAART AS 31 DEC 2012

15,028 on ARV in 2012

39,000 Adult Eligible for ARV in 2012 (EPP Model)

39,000 Adult Eligible for ARV in 2012 (EPP Model)

Expenditure 2008 2012

0

10000000

20000000

30000000

40000000

50000000

60000000

2008 2009 2010 2011 2012

Global Fund

Domestic

ARV : 2011 USD 16.10 mil 2012 USD 20.41 mil

USD 16.76 1st Line ARV USD 3.65 2nd Line ARV

Expenditu

re (

US

D)

DOMESTIC FUND FOR HIV WORKS

38%

BATTLE AGAINST HIV/AIDS

ARE WE WINNING?

YES , WE ARE ON TRACK!


ARE WE WINNING?

PART 2

MALARIA

6c: HAVE HALTED AND BEGUN TO REVERSE THE INCIDENCE

OF MALARIA AND OTHER MAJOR DISEASES BY 2015

MALARIA Have achieved target of halting and reversing the incidence of malaria

Can we really win the fight against malaria? In the past ten years, increased investment in malaria prevention and control has saved more than a million lives,

This is a tremendous achievement. But we are still far from achieving universal access to life-saving malaria interventions.

Until countries are able to test, treat, and report every malaria case, we will never defeat this disease,

"We need strong and sustained political commitment from all

countries where malaria is endemic, and from the global health

community, to see this fight through to the end.

Dr Margaret Chan, WHO Director-General.

GLOBAL MALARIA

Malaria is a life-threatening disease

caused by parasites that are

transmitted to people through the

bites of infected mosquitoes.

In 2010, there were about 219 million

cases of malaria and an estimated

660 000 deaths globally.

Approximately half of the world's population is at risk

of malaria. Most malaria cases and deaths occur in sub-

Saharan Africa.

In 2011, 99 countries and territories had ongoing

malaria transmission.

24

3,8

70

18

1,4

95

15

1,8

22

87

,43

2

44

,22

6

49

,52

6

48

,00

7

41

,70

8

55

,06

8

69

,12

7

50

,50

0

39

,18

9

36

,85

3

39

,89

0

58

,95

8

59

,20

8

51

,92

1

26

,64

9

13

,49

1

11

,10

6

12

,70

5

12

,78

0

11

,01

9

6,3

38

6,1

54

5,5

69

5,2

94

5,4

56

7,3

90

7,0

10

6,6

50

5,3

06

4,7

25

0

50,000

100,000

150,000

200,000

250,000

300,000

MALARIA IN MALAYSIA

1961 Malaria Eradication Programme (Sabah & Sarawak)

1967 Malaria Eradication Programme (Peninsular Malaysia)

1980 Malaria Control Programme

2011 National Strategic Plan for Elimination of Malaria (2011-2020)

In 1961, there were 243,870 malaria cases reported in Malaysia while in 1990, the cases have declined to 50,500.

A decade later, in the year 2000, the number of reported cases have further decreased to 12,705 cases.

In 2012, there were 4,725 cases which is a 63% reduction compared to 2000.



MALARIA Have achieved target of halting and reversing the incidence of malaria

Malaysia has achieved the MDG goal for malaria well ahead of the 2015 deadline and has built on these achievements to strengthen current efforts and secure further commitments towards elimination by 2020 which is the target for Malaysias MDG-Plus.

The incidence of malaria has declined from 289.5 per 100,000 populations in 1990 to 54.6 per 100,000 populations by year 2000 and to 16.4 per 100,000 populations in 2012. (Target to reduce to 27.3 per 100,000 by 2015 but achieved much earlier)

There has also been a reduction in the number of malaria deaths from 43 in 1990 to 35 in 2000 and to 16 deaths in 2012. The mortality rate due to malaria has been around 0.1 per 100,000 population since 2006.

MALAYSIA: NSP MALARIA, MALARIA

ELIMINATION 2011 - 2020

STRATEGY

1. Early case detection & prompt treatment

2. Close monitoring of imported cases

3. Residual spraying

4. Usage of bednets

5. Environmental management & anti larva.

6. Monitoring of drug resistance

7.Collaboration with the neighbouring countries

2011 - 2015 2011 - 2017

GENERAL OBJECTIVE

o To ensure Malaysia is free from local malaria transmission by 2020

SPECIFIC OBJECTIVES

o Peninsular Malaysia malaria free by 2015

o Sabah & Sarawak malaria free by 2017

CHALLENGES

Malaria transmission in Sabah and Sarawak.

Malaria transmission among migrant workers.

Ensuring effective and efficient malaria prevention and control measures.

Inaccessible remote areas especially in Sabah and Sarawak

Zoonotic infection (Plasmodium knowlesi)

Control activities at the border areas

BATTLE AGAINST MALARIA

ARE WE WINNING?

YES , WE ALREADY WIN THE GAME!


ARE WE WINNING?

PART 3

TUBERCULOSIS

Myanmar

Thailand

Cambodia

Viet Nam

Philippines

Indonesia

Indonesia

Sabah

SarawakJohorKL

Pinang

MANAGING TB SITUATION IN MALAYSIA

The National Tuberculosis Control Programme (NTBCP) in Malaysia was launched in 1961 as a vertical programme with the main aim to control and reduce the prevalence of tuberculosis as a public health concern. BCG Vaccination program was introduced as one of the strategies of NTBCP in the same year. In 1995, the programme was integrated into the general medical and health system following WHOs recommendation and implementation of primary care concept in Malaysia. Ministry of Health is the leading agency in NTBCP and collaborates with other ministries and relevant non governmental agency for this course.

Malaysia is classified as a country with an intermediate TB burden, that is, with an incidence of between 20-100 reported cases per 100,000 population annually.

Since the implementation of national TB Control Program in 1961, the number of reported TB cases had successfully reduced to from 350 cases per 100,00 to less than 100 per 100,000 in 1980s. However, since then reported TB cases has remained unchanged between 60 to 68 per 100,000 population. It was noted that the reported TB cases had show slight increment since 2004.

Tuberculosis in the World

Incidence: 9.5 million new cases/year

Prevalence: 14 million cases

95% of cases in resource poor settings

1.1 millions co-infection TB/ HIV

(12% HIV Positive have TB)

1.7 millions deaths/year

98% deaths in poor resource countries

WHO 2010

Incidence Rate and Mortality Rate Of Communicable Disease 2012

(per 100,000 population) Communicable Disease Incidence Rate Mortality Rate

Food and Water Borne Disease

Cholera 0.96 0.003

Dysentry 0.29 0.000

Food Poisoning 44.93 0.003

Typhoid 0.75 0.003

Hepatitis A 1.58 0.000

Vector Borne Disease

Dengue 72.20 0.000

Dengue Haemorrhagic Fever 2.45 0.119

Malaria 16.11 0.050

Typhus 0.03 0.000

Plague 0.00 0.000

Yellow Fever 0.00 0.000

Vaccine Preventable Disease

Acute Poliomyelitis 0.00 0.000

Diphtheria 0.00 0.000

Measles 6.39 0.000

Other Tetanus 0.08 0.010

Neonatal Tetanus 0.02 0.004

Hepatitis B 8.99 0.070

Whooping Cough 0.76 0.010

Sexually Transmitted Disease

Chancroid 0.00 0.000

Gonorrhoea 5.09 0.000

Syphilis 5.70 0.003

Other Infectious Disease

HIV 11.72 0.570

AIDS 4.64 1.820

Ebola 0.00 0.000

Hepatitis C 5.91 0.109

Hand, Foot & Mouth Diseases 117.67 0.003

Leprosy 1.10 0.000

Other Specified Viral Hepatitis 0.26 0.000

Rabies 0.00 0.000

Relapsing Fever 0.00 0.000

Tuberculosis 77.41 4.900

Viral Encephalitis 0.08 0.006

H1N1 0.93 0.010

Leptospirosis 12.49 0.164

Influenza 2.90 0.024

Source: Disease Control division, MOH

18 304 new TB cases (mean ~ 50 cases /day)

1414 TB death (mean ~ 4 death/day)

Source: Disease Control

Division, Ministry of Health,

2012

Incidence Rate (Notification Rate) of TB in

Malaysia, 1990-2012

127

95

82 81 78

61 65 68

72 77

0

20

40

60

80

100

120

140

Rate/100,000

Year

WHO Estimated Incidence R per 100,000 1990-2020Malaysia Reported Incidence Rate (Notification Rate) per 100,000, 1990-2012

1. Not achieving WHO estimated incidence case

2. WHO Estimation Notification Rate (NR) downwards trend 3. Actual NR increasing (CDR 2011: 85%, 2012 :95%)

Malaysia: TB Mortality Rate, 1990-2012

Year

26.0

13.0

8.5 8.2 7.9 7.1

4.2 4.4 5.6 5.5 5.5 5.8 4.9

0.0

5.0

10.0

15.0

20.0

25.0

30.0

19

90

19

91

19

92

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

20

13

20

14

20

15

20

16

20

17

20

18

20

19

20

20

Rate/100,000

WHO Estimated Mortality Rate (Excluding TBHIV Mortality) per 100,000, 1990-2020

Malaysia Reported TB Mortality per 100,000, 1990-2012

a

1. WHO estimated mortality rate (MR) is excluding TBHIV mortality

2. Actual MR : 1990-2011 including TBHIV mortality; 2012 excluding TBHIV mortality.

3. WHO estimated MR downward trend 4. Actual MR : plateau since 1990

Year

050

100

150

200

250

1990 1995 2000 2005 2010 2015

Prevalence

0

5

10

15

20

25

30

1990 1995 2000 2005 2010 2015

Mortality

Ca

ses p

er

10

0,0

00 p

opu

lation

Death

s p

er

100,0

00 p

opula

tion

TB prevalence and mortality, Malaysia

Target = 113 Target = 13

107 8.5

227 26

2005 2006 2007 2008 2009 2010 2011

Not evaluated 12 42 15 9 8 7 8

Failed 0 0 0 0 0 0 0

Defaulted 10 3 5 4 4 4 4

Died 8 6 8 8 9 9 9

Complete 1 3 5 1 1 1 1

Cure 69 46 67 78 78 79 78

0

20

40

60

80

100%

Treatment Outcome New Smear Positive Cases, Cohort 2005-2011

Cure Rate shows improvement . Management of TB patient need to strengthen especially on

detection of default cases and on decreasing deaths during TB treatment (TBHIV).

Treatment Outcome New Smear Positive

Cases, Cohort 2005-2011

2005 2006 2007 2008 2009 2010 2011

Not evaluated 12 42 15 9 8 7 8

Failed 0 0 0 0 0 0 0

Defaulted 10 3 5 4 4 4 4

Died 8 6 8 8 9 9 9

Complete 1 3 5 1 1 1 1

Cure 69 46 67 78 78 79 78

0

20

40

60

80

100%

Treatment Outcome New Smear Positive Cases, Cohort 2005-2011

Cure Rate shows improvement . Management of TB patient need to strengthen especially

on detection of default cases and on decreasing deaths during TB treatment (TBHIV).

Cure Rate States in Malaysia, Cohort 2010,2011 & 2012

Target 85%

0 15 30 45 60 75

Perlis

Kedah

P.Pinang

Perak

Selangor

WP(KL)

N.Sembilan

Melaka

Johor

Pahang

Terengganu

Kelantan

WP(Labuan)

Sabah

Sarawak

MALAYSIA

Cohort 2011 Cohort 2010 Cohort 2009

TB control in Malaysia: 1995-2015 Special Project (2000 2010)

2000 2005 1995 2010

Impact targets

Intermediate targets

70% Case Detection

85% Treatment success

100% DOTS Coverage

TB Control

integrated to

Public Health

2015

MDG

Reverse

Policies

Notification of TB under CDC Act 1988

National Tuberculosis Information System (TBIS 2002)

Practice Guidelines For The Control

And management of TB 2nd edition 2002

BCG

Guidelines on TB in Prison

Guidelines on TB in Rehabilitation Centre

Direct Smear Microscopy 2000

MALAYSIA NSP TO CONTROL TB

Malaysia National Strategic Plan 2011-2015

Vision

To reduce the burden of TB

Goal

To accelerate the reduction of TB related

morbidity and mortality towards the

achievement of the TB related MDG

targets by 2015.

NSP To Control TB

2011-2015

Strategies

3. Delivering, enhancing and

expanding high-quality TB treatment

4. Empower people with TB

and the community

5. Limiting people from

contracting TB

6. Promote TB centered research

1.Strengthening components of health system

2. Enhancing case detection of

TB

*HCW

98

Migrant

127

Elderly

132

*DM

351

Close Contact

708

Prisoner

752

Drug Rehabilitation Inmates

937

HIV positive

1782

TB

Burden

in

General

Population :

77 per 100,000

*HCW- Health Care Worker

*DM-Diabetes Mellitus

High Risk Groups



TUBERCULOSIS Have achieved target of halting and reversing the incidence of

tuberculosis

Have not achieved target of halting and reversing the incidence of tuberculosis. Unlikely to

achieve by 2015

127

95

82 81 78

61 65 68 72

77

0

20

40

60

80

100

120

140

Rate/100,000

Year

Estimation by WHO

Actual Incidence

BATTLE AGAINST TUBERCULOSIS

ARE WE WINNING?

NOT YET!, NEED INNOVATIVE AND

VIGOROUS APPROACH TO WIN THE GAME!

plenary 3-kuantan fms sesi mdg 0800 060713

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