PREVENTION & CONTROL OF COMMUNICABLE & NONCOMMUNICABLE DISEASE

Group 2 Megat, Jot , Harliyana, Marcus, Gaveen

 Communicable disease
I. Common communicable diseases in Malaysia II. National policies & procedures III. Prevention & control of 3 common communicable diseases in Malaysia Non-communicable disease I. Common non-communicable diseases in Malaysia II. Prevention & control of 3 common noncommunicable diseases in Malaysia

COMMUNICABLE DISEASE

Communicable Disease In Malaysia

COMMUNICABLE DISEASE 1. DENGUE

Introduction
Dengue is a viral infection transmitted by mosquitoes, mainly the Aedes aegypti species The virus is contracted from the bite of a striped Aedes aegypti mosquito that has previously bitten an infected person. One mosquito bite can inflict the disease There are four strains or serotypes of dengue virus namely DEN-1, DEN-2, DEN-3 and DEN-4 The mosquito flourishes during rainy seasons but can breed in water-filled containers, year-round

Introduction
The virus is not contagious and cannot be spread directly from person to person. There must be a person-to-mosquito-to-another-person pathway Dengue haemorrhagic fever severe form of dengue. A second attack by dengue virus of a different serotype from the first infection Approximately 1% of patients with dengue infection progress to dengue haemorrhagic fever

World-Wide Distribution

Hospital Infection & Antibiotic Control Committee

1902 - The earliest recorded case of dengue fever in

Malaysia Penang 1962 The first major dengue outbreak in Malaysia Penang 1973 A nationwide outbreak Kuala Lumpur Since then dengue has become a major public health problem in the country Dengue cases/deaths mounts parallel with the rapid development, expansion of urban areas & population density (as of Sept 2008 = 27,730,000 inhabitants)

Dengue Incidence From 1998-2008 In Malaysia

Year Case Death
Reported Dengue Cases in Malaysia
50000 45000 40000 35000 30000 25000 20000 15000 10000 5000 0

1998
1999 2000 2001 2002 2003

27381
10146 7103 16386 15493 31545

82
37 45 50 54 72

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

2004
2005 2006 2007 2008

33895
39654 34386 48846 49355

102
107 70 98 112
120 100 80 60 40 20 0 1998 1999 2000 2001 2002 37 45 50 82

Year

Reported Dengue Deaths in Malaysia

112 98 70

102 72 54

107

P/S : 28.12.2008 03.01.2009, 1157 cases were reported with 4 deaths so far

2003

2004

2005

2006

2007

2008

Year

Diagnosis
Classic symptoms : high fever, a petechial rash with thrombocytopenia & relative leukopenia (decrease in the number of circulating WBC in the blood) WHO definition of DHF: I. Fever II. Haemorrhagic tendency [positive tourniquet test (> than 20 petechiae per square inch), spontaneous bruising, bleeding from mucosa, gingiva, injection sites, vomiting blood or bloody diarrhea] III. Thrombocytopaenia [<100,000 platelets per mm]. IV. Evidence of plasma leakage [rise in hematocrit level > than 20%] Serology (identification of antibodies in the blood serum) & polymerase chain reaction (PCR) to confirm the diagnosis of dengue if clinically indicated

Symptoms
Sudden high fever (39-41.5C) for 2 to 7 days Headache Pain behind the eyes Muscle pain, joint pain, bone pain (break-bone fever) After 1 to 2 days of fever, the patient develops initial rash with discoloured spots, often described as Isles of white in a sea of red Second rash may develop to palms and soles, and skin may peel off (desquamate) & body temperature drops

Treatments
No specific antiviral treatment, only supportive treatment is given to such patients If the patient is dehydrating, adequate fluids are to be taken Intravenous fluid is administered if the patient is unable to maintain oral intake For severe body ache, painkillers may be needed For severe headache and for joint and muscle pain, acetaminophen/paracetamol and codeine may be given If there is significant bleeding, blood or platelet transfusion will be carried out Note : Aspirin should be avoided as this drug may worsen the bleeding tendency (because of its anticoagulant effects & the increased risk of developing Reye syndrome).

COMMUNICABLE DISEASE 2. TUBERCULOSIS

 Tuberculosis is mainly caused by

Introduction

Mycobacterium tuberculosis, a small, Aerobic, non-motile bacillus When people with active pulmonary TB cough, sneeze, speak, sing, or spit, they expel infectious aerosol droplets 0.5 to 5.0 m in diameter A single sneeze can release up to 40,000 droplets Each 1 of these droplets may transmit the disease, since the infectious dose of tuberculosis is very small (the inhalation of fewer than 10 bacteria may cause an infection)

Diagnosis

Diagnosis of tuberculosis involves

clinical, radiological and/ or bacteriological evidence. The commonest form of tuberculosis in adults is post-primary pulmonary tuberculosis. It is the only form of tuberculosis which is infectious and thus has great epidemiological significance The tuberculin or Mantoux test has some role in the diagnosis of tuberculosis especially in paediatric cases and cases of extra-pulmonary tuberculosis The Mantoux test is used in Malaysia using the strength of 10 IU PPD. Result is read after 72 hours

Signs & Symptoms

Symptoms which suggest pulmonary tuberculosis

include: I. Cough, usually more than two weeks II. Cough with sputum which is occasionally blood stained loss of appetite and weight III. Fever IV. Dypsnoea, night sweats,chest pain and hoarseness of voice, all of which are not common Signs can be subtle as in minimal cases or obvious such as consolidation, fibrosis or stony dullness due to pleural effusion

Investigations

Sputum direct smears using Ziehl-Neelsen stain for

acid fast bacilli which are usually positive in cavitary disease Cultures using Lowenstein-Jensen medium take up to 8 weeks for a final result Chest X-rays often reveal lesions in the apical and posterior segments of the upper lobes Lesions are often soft in active pulmonary tuberculosis and there is usually no or little fibrosis or calcification. These latter findings would suggest healed tuberculosis

Treatment

First Line Drug Five drugs are considered essential

to the treatment of tuberculosis. They are: 1. Isoniazid (H) 2. Rifampicin (R) 3. Pyrazinamide(Z) 4. Streptomycin(S) 5. Ethambutol (E)

Treatment
Description of regimen Intensive Phase: Daily doses x 2 months (Total of 56 doses) SHRZ SHR EHRZ RHZ Continuation Phase: Biweekly doses x4 months (Total of 32 doses) SHR RH RH (daily)

8 weeks daily SHRZ 16 weeks biweekly 8 weeks daily EHRZ 16 weeks biweekly RH 8 weeks daily RHZ 16 weeks daily RH (preferred regimen for paediatric cases) 8 weeks daily SHRZ 16 weeks biweekly RH 8 weeks daily RH 16 weeks biweekly RH

SHRZ RHZ

RH RH

COMMUNICABLE DISEASE 3. HUMAN IMMUNODEFICIENCY VIRUS (HIV)

Introduction

Human Immunodeficiency Virus A unique type of virus (a retrovirus) Invades the helper T cells (CD4 cells) in the body of

Threatening a global epidemic Preventable, manageable but not curable

the host (defense mechanism of a person)

Introduction

Acquired Immunodeficiency Syndrome HIV is the virus that causes AIDS Disease limits the bodys ability to fight infection due to markedly reduced helper T cells mechanism)

Patients have a very weak immune system (defense

Patients predisposed to multiple opportunistic
infections leading to death

Definition Of AIDS

Opportunistic infections and malignancies that rarely

occur in the absence of severe immunodeficiency (eg, Pneumocystis pneumonia, central nervous system lymphoma) Persons with positive HIV serology who have ever had a CD4 lymphocyte count below 200 cells/mcL or a CD4 lymphocyte percentage below 14% are considered to have AIDS

Transmission

Through bodily fluids

I. Blood products II. Semen III. Vaginal fluids Intravenous drug abuse I. Sharing Needles (Without sterilization increases the chances of contracting HIV) II. Unsterilized blades

Transmission

Through sex
I. Oral II. Anal Mother to babies I. Before birth II. During birth

Stage 1 - Primary

Short, flu-like illness - occurs one to six Mild symptoms Infected person can
infect other people weeks after infection

Stage 2 - Asymptomatic

Lasts for an average of ten years This stage is free from symptoms There may be swollen glands The level of HIV in the blood drops to low levels HIV antibodies are detectable in the blood

Stage 3 - Symptomatic

The immune system deteriorates Opportunistic infections and cancers start to appear

Stage 4 HIV & AIDS

The immune system weakens too much as CD4 cells

decrease in number

Opportunistic Infections Associated With AIDS & HIV

CD4<500 Bacterial infections Tuberculosis (TB) Herpes Simplex Herpes Zoster Vaginal candidiasis Hairy leukoplakia Kaposis sarcoma

Opportunistic Infections Associated With AIDS & HIV

CD4<200 Pneumocystic carinii Toxoplasmosis Cryptococcosis Coccidiodomycosis Cryptosporiosis Non hodgkins lymphoma

Opportunistic Infections Associated With AIDS & HIV

CD4<50 Disseminated mycobacterium avium complex (MAC) infection Histoplasmosis CMV retinitis CNS lymphoma Progressive multifocal leukoencephalopathy HIV dementia

Tuberculosis & HIV Infection

TB is the most common opportunistic infection in HIV

and the first cause of mortality in HIV infected patients (10-30%) 10 million patients co-infected in the world. Immunosuppression induced by HIV modifies the clinical presentation of TB: I. Subnormal clinical and roentgen presentation II. High rate of MDR/XDR III. High rate of treatment failure and relapse (5% vs < 1% in HIV)

Investigations

Investigations

Urine Western Blot

I. As sensitive as testing blood II. Safe way to screen for HIV III. Can cause false positives in certain people at high risk for HIV

Investigations

Orasure
I. The only FDA approved HIV antibody II. As accurate as blood testing III. Draws blood-derived fluids from the gum tissue IV. NOT A SALIVA TEST!

Treatment

HAART = highly active anti-retroviral treatment

Treatment

Antiretroviral Drugs (HAART)

Nucleoside Reverse Transcriptase inhibitors AZT (Zidovudine) II. Non-Nucleoside Transcriptase inhibitors Viramune (Nevirapine) III. Protease inhibitors Norvir (Ritonavir) I.

COMMUNICABLE DISEASE NATIONAL POLICIES & PROCEDURES

Hospital Infection & Antibiotic Control Committee

HIACC of MOH is responsible for developing policies

and procedures related to infection control and antibiotic usage in the hospital and its affiliated health facilities HIACC will act as a source of expertise on matters relating to infection and antibiotic usage HIACC advises the Hospital Director on the technical matters related to Infection Control in the hospital The policies and procedures of the HIACC should be in line with the principles and general policies set out by the National Infection and Antibiotic Control Committee (NIACC)

Infection Control Doctor (ICD)

The ICD is the Chairman of HIACC and is responsible

for the day-to-day management of infection control in the hospital The ICD will be appointed by the hospital director and should have appropriate training and experience in matters relating to infection and antibiotic control Infection control should make up a portion of his/her daily activities The ICD will refer to the HIACC for major matters of policy development and for the management of outbreaks in accordance to the major outbreak policy

Membership Of HIACC

The Infection Control Doctor (Chairman) Medical Microbiologist (if not available, scientific officer in microbiology) The Infectious Disease Physician / Paediatrician The Infection Control Sister or the most senior infection control nurse (ICN) The Director /Deputy Director of the hospital A consultant virologist A consultant physician or surgeon A consultant pediatrician A consultant anaesthesiologist /intensivist A representative each from all major clinical departments (preferably at specialist or consultant level) The Nursing Director A pharmacist Senior representative from the hospital support service concessionaire

COMMUNICABLE DISEASE 1. TUBERCULOSIS

1. Administrative control (managerial) The most important measures of TB infection control is to prevent exposure and reduce transmission to health care workers and patient: I. Written TB Infection Control Plan II. Workplace Risk Assessment III. Triage and screening of patients IV. Early diagnosis, prompt treatment and isolation V. Training and education of health care workers VI. Patient education

2. Environmental control Prevent the spread & reduce the concentration of infectious droplet in the air Type of environmental control includes: I. Maximizing natural ventilation through open and free flow ambient air with open windows II. More complex methods: o Ventilation system e.g. local exhaust ventilation (LEV) o Negative pressure rooms or airborne infection isolation (AII) room o High Efficiency Particulate Air (HEPA) filtration to remove infectious particles o Ultraviolet germicidal irradiation (UVGI) to sterilize the air

3. Personnel protective equipment (PPE) The use of appropriate PPE is important and HCW must be trained to use PPE correctly 4. Screening for HCW I. Health care workers should be screened for Tuberculosis whenever they are symptomatic II. Chest radiograph and Tuberculin Skin Test are not routinely recommended 5. Infection control in specific area I. Inpatient settings II. Sputum induction area or room III. Outpatient settings and emergency department IV. Pharmacy

I. Inpatient setting Placed in AII room (Airborne Infection Isolation /Negative Pressure) TB patients should be cohorted from non tuberculosis patient, infectious from non infectious TB patients Isolation ward or area with maximum natural ventilation, mechanical ventilation by local exhaust ventilation and air cleaning methods

I. Inpatient setting All patients suspected or confirm TB should be educated about the importance of cough etiquette and wear surgical mask or close the mouth/nose when sneezing or coughing All HCW should use PPE (N95 mask) when handling infectious, non infectious or unconfirmed cases TB Only minimum number of visitors should be allowed to visit active TB patient in the ward. Protections for visitor are similar to medical staff

II. Sputum induction area/room An area or room with local exhaust ventilation (e.g., booths with special ventilation) or alternatively in a room that meets the requirements of an AII room N95 disposable respirator should be worn by HCWs performing sputum inductions on a patient with suspected or confirmed infectious TB disease After sputum induction is performed, allow adequate time before performing another procedure in the same room

III. Outpatient & Emergency Department Triage: o Triaging patient at the counter should be done to identify high risk patients by history taking (patient with history of cough for more than 2 weeks) o Specific waiting area or room for patients are recommended Signage directing patients with chronic cough to go to specific or identified counter. These patients should be provided with surgical mask. Provide N95 respirator for HCW in-charge of triaging

III. Outpatient & Emergency Department Educate patient with suspected or confirmed infectious TB disease on strict respiratory hygiene and cough etiquette Sputum induction room should be made available at OPD Ideally patients should be seen in a designated consultation room for TB equipped with appropriate environmental control

IV. Pharmacy Cut down patient mix/movement at pharmacy. Patient to collect medication at chest clinic or special counter at pharmacy or other options Dispensing should be done at special counter and positive pressure from pharmacy area out Allocate special code number or counter for TB infectious patients to collect medications Pharmacist or assistant pharmacist on duty at that counter must wear N95 mask when dealing with TB infectious patients Provide priority service to TB patients

V. Bronchoscopy suite Postpone non-urgent procedures on TB patients until the patient is determined to be noninfectious In urgent cases (e.g. massive haemoptysis), bronchoscopist and the assistants should wear N95 respirator and face shield for protection Air cleaning system should be installed in the bronchoscopy suite Ventilation system must be operated and maintained efficiently Tuberculosis culture laboratory must have a wellmaintained and properly functioning biological safety

VI. Laboratories All specimens suspected of containing M. tuberculosis (including specimens processed for other microorganisms) should be handled in a Class I or II biological safety cabinet (BSC) Standard personal protective equipment should be available and consists of:
o Laboratory coats - which should be left in the laboratory before going to non-laboratory areas o Disposable gloves - Gloves should be disposed of when work is completed, the gloves are overtly contaminated, or the integrity of the glove is compromised o Face protection (e.g., goggles, full-face piece respirator, face shield, or other splatter guard) should also be used when manipulating specimens inside or outside a BSC o Respiratory protection (N95) should be worn

COMMUNICABLE DISEASE 2. HIV

 Standard chemical germicides at concentrations much

lower than commonly used in practice can rapidly inactivate HIV Reusable instruments or devices should be sterilized or receive high-level disinfection before reuse Cleaning and removal of soil should be done routinely Germicide effective against HIV is a solution of sodium hypochlorite (1 part household bleach to 99 parts water or 1/4 cup bleach to 1 gallon of water) prepared daily Bleach, however, is corrosive to metals (especially aluminum) and should not be used to decontaminate medical instruments with metallic parts

 Chemical germicides that are tuberculocidal/virucidal

used to decontaminate spills of blood or other body fluids In patient-care areas, visibly soiled areas should first be cleaned and then chemically decontaminated (moistened with germicide and air dry) In the laboratory, large spills of cultured or concentrated infectious agents should be flooded with a liquid germicide before cleaning, then decontaminated with fresh germicidal chemical after organic material has been removed

 Gloves should always be worn during cleaning and

decontaminating procedures CDC recommends barrier precautions (face shields, masks, gowns, etc.) to prevent contact with droplets and splashes

COMMUNICABLE DISEASE 3. DENGUE

1. Patients isolation I. Dengue patient need not be nursed in isolation room but an air-conditioned or an naturalventilated room is preferred II. If a natural-ventilated room is used, it is suggested to put mosquito nets to all the windows in the room III. If both facilities are not available, then the patients can be nursed in the general ward IV. Specific measures to avoid mosquito bites should be considered

2. Prevention of vector transmission I. Source elimination/reduction for Dengue fever II. Source elimination or reduction is the method of choice for mosquito control when the mosquito species targeted are concentrated in a small number of discrete habitats

2. Prevention of vector transmission III. Among the suggested measures to make sure that there will be no breeding grounds for mosquito in the area are: The larval habitats may be destroyed by filling depressions that collect water, by draining swamps, or by ditching marshy areas to remove standing water Container-breeding mosquitoes need to be identified and removed

2. Prevention of vector transmission III. Among the suggested measures to make sure that there will be no breeding grounds for mosquito in the area are: Water in cans, cups, and rain barrels around hospitals should be covered Chemical insecticides can be applied directly to the larval habitats Other methods, which are less disruptive to the environment, are usually preferred: o Oil may be applied to the water surface, suffocating the larvae and pupae o oil in use today are rapidly biodegraded

3. Biological agents Toxins from the bacterium Bacillus thuringiensis var. israelensis (Bti) I. These products can be applied in the same way as chemical insecticides II. Very specific, affecting only mosquitoes, black flies, and midges III. Insect growth regulators such as methroprene. Methoprene is specific to mosquitoes IV. Mosquito fish (Gambusia affinis) are effective in controlling mosquitoes in larger bodies of water

4. Avoidance from mosquito bite I. Insect repellents containing N,N-diethyl-3methylbenzamide (DEET) Adult-dose 95% DEET lasts as long as 10-12 hours, and 35% DEET lasts 4-6 hours Children, use concentrations of less than 35% DEET. Use sparingly and only on exposed skin. Remove DEET when no longer exposed II. Protective clothing (most effective is permethrinimpregnated) Limiting exposure during times of typical blood meals Wearing long-sleeved clothing

III. Insecticide-treated bed nets limited since Aedes mosquitoes bite during the day IV. Insecticides knockdown resistance may occur in some locations. Aedes mosquitoes bite during the day; hence, these measures must be taken during the day, particularly in the morning and late afternoon V. Fogging or area spraying is primarily reserved for emergency situations: Halting epidemics or rapidly reducing adult mosquito populations Fogging and area sprays must be properly timed to coincide with the time of peak adult activity

NON-COMMUNICABLE DISEASE

Proportional Mortality In Malaysia (2010)

Behavioural & Metabolic Risk Factors Trend In Malaysia

NON-COMMUNICABLE DISEASE 1. CARDIOVASCULAR DISEASE

Introduction

Cardiovascular disease includes numerous problems,

many of which are related to a process called atherosclerosis Atherosclerosis is a condition that develops when plaque builds up in the walls of the arteries This buildup narrows the arteries, making it harder for blood to flow through. If a blood clot forms, it can stop the blood flow. This can cause a myocardial infarction or stroke

Types Of Cardiovascular Disease

Myocardial infarction Stroke (cerebrovascular accident) Heart failure Arrhythmia Valvular heart disease

Clinical Manifestations

Chest discomfort Peripheral edema & pulmonary congestion Dyspnea Palpitations Hypotension Syncope Heart murmur Elevated arterial pressure Abnormal ECG

Diagnosis
1. The underlying etiology Is the disease congenital, hypertensive, ischemic, or inflammatory in origin? 2. The anatomical abnormalities Which chambers are involved? Are they hypertrophied, dilated, or both? Which valves are affected? Are they regurgitant and/or stenotic? Is there pericardial involvement? Has there been a myocardial infarction? 3. The physiological disturbances Is an arrhythmia present? Is there evidence of congestive heart failure or myocardial ischemia?

Diagnosis
4. Functional disability. How strenuous is the physical activity required to elicit symptoms? The classification provided by the NYHA has been found to be useful in describing functional disability

Investigations
1. ECG 2. Non-invasive imaging (echocardiogram, radionuclide imaging, computed tomographic imaging, magnetic resonance imaging) 3. Blood tests (lipid determinants, C-reactive protein, cardiac function [BNP]) 4. Specialized invasive examination (cardiac catheterization, coronary arteriography) 5. Genetic test (monogenic cardiac disease)

Investigations
1. ECG 2. Non-invasive imaging (echocardiogram, radionuclide imaging, computed tomographic imaging, magnetic resonance imaging) 3. Blood tests (lipid determinants, C-reactive protein, cardiac function [BNP]) 4. Specialized invasive examination (cardiac catheterization, coronary arteriography) 5. Genetic test (monogenic cardiac disease)

Prevention
Control of risk factors Achieving optimal weight Physical activity Smoking cessation Diet control and balance Management of hypertension Management of hyperlipidemia Management of diabetes mellitus

Management
1. Continual assessment & re-assessment of health 2. Patient education of lifestyle changes and compliance to follow-up and therapies 3. Medical therapy antiplatelet therapy, lipid-lowering therapy (statin), antihypertensive therapy, hypoglycemic therapy * Not recommended hormone replacement, vitamin B, C, E, folate (for reduction of cardiovascular risk) 4. Surgical therapy coronary revascularization (CABG, PTCA), carotid endarterectomy

NON-COMMUNICABLE DISEASE 2. CANCER

Introduction

Cancer is a generic term for a large group of diseases

that can affect any part of the body Other terms used are malignant tumours and neoplasms One defining feature of cancer is the rapid creation of abnormal cells that grow beyond their usual boundaries, and which can then invade adjoining parts of the body and spread to other organs This process is referred to as metastasis. Metastases are the major cause of death from cancer

Pathophysiology

Cancer arises from one single cell. The transformation

from a normal cell into a tumour cell is a progression from a pre-cancerous lesion to malignant tumours These changes are the result of the interaction between a person's genetic factors and three categories of external agents, including:
I. Physical carcinogens, such as ultraviolet and ionizing radiation II. Chemical carcinogens, such as asbestos, components of tobacco smoke, aflatoxin (a food contaminant) and arsenic (a drinking water contaminant) III.Biological carcinogens, such as infections from certain viruses, bacteria or parasites

Pathophysiology

Ageing is another fundamental factor for the

development of cancer The incidence of cancer rises dramatically with age, most likely due to a build up of risks for specific cancers that increase with age The overall risk accumulation is combined with the tendency for cellular repair mechanisms to be less effective as a person grows older

Risk Factors

Tobacco use Alcohol use Unhealthy diet Physical inactivity

Low-middle income countries Chronic infections from hepatitis B (HBV), hepatitis C virus (HCV) and some types of Human Papilloma Virus (HPV) Cervical cancer, which is caused by HPV, is a leading cause of cancer death among women in low-income countries

Prevention

Increase avoidance of the risk factors Vaccinate against human papilloma virus (HPV) and
hepatitis B virus (HBV) Control occupational hazards Reduce exposure to sunlight Early detection Early diagnosis Screening

Modifying & Avoiding Risk Factors

Tobacco use Being overweight or obese Unhealthy diet with low fruit and vegetable intake Lack of physical activity Alcohol use Sexually transmitted HPV-infection Urban air pollution Indoor smoke from household use of solid fuels

Management
Treatment goal is to cure disease, or prolong life while improving quality of life Surgery Radiotherapy Chemotherapy

Palliative care relieve rather than cure, symptoms caused by cancer Live more comfortably Relief from physical, psychosocial & spiritual problems

Palliative Care Strategies

Effective public health strategies, comprising of

community- and home-based care are essential to provide pain relief and palliative care for patients and their families in low-resource settings Improved access to oral morphine is mandatory for the treatment of moderate to severe cancer pain, suffered by over 80% of cancer patients in terminal phase

NON-COMMUNICABLE DISEASE 3. RESPIRATORY DISEASE

Introduction

Respiratory tract diseases are diseases that affect the

air passages, including the nasal passages, the bronchi and the lungs They range from acute infections, such as pneumonia and bronchitis, to chronic conditions such as asthma and chronic obstructive pulmonary disease

Asthma

Asthma is characterized by recurrent attacks of

breathlessness and wheezing, which vary in severity and frequency from person to person Symptoms may occur several times in a day or week in affected individuals, and for some people become worse during physical activity or at night During an asthma attack, the lining of the bronchial tubes swell, causing the airways to narrow and reducing the flow of air into and out of the lungs Recurrent asthma symptoms frequently cause sleeplessness, daytime fatigue, reduced activity levels and school and work absenteeism

Asthma Causes
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, such as: 1. Indoor allergens (for example, house dust mites in bedding, carpets and stuffed furniture, pollution and pet dander) 2. Outdoor allergens (such as pollens and moulds) 3. Tobacco smoke 4. Chemical irritants in the workplace 5. Air pollution

Asthma Causes

Other triggers can include cold air, extreme emotional

arousal such as anger or fear, and physical exercise Even certain medications can trigger asthma: aspirin and other non-steroid anti-inflammatory drugs, and beta-blockers (which are used to treat high blood pressure, heart conditions and migraine) Urbanization has been associated with an increase in asthma. But the exact nature of this relationship is unclear

Chronic Obstructive Pulmonary Disease (COPD)

Chronic obstructive pulmonary disease (COPD) is a

lung ailment that is characterized by a persistent blockage of airflow from the lung It is an under-diagnosed, life-threatening lung disease that interferes with normal breathing and is not fully reversible The more familiar terms of chronic bronchitis and emphysema are no longer used; they are now included within the COPD diagnosis

COPD Symptoms

Breathlessness (or a "need for air") Abnormal sputum (a mix of saliva and mucus in the
airway) Chronic cough Daily activities, such as walking up a short flight of stairs or carrying a suitcase, can become very difficult as the condition gradually worsens

COPD Risk Factors

COPD is preventable The primary cause of COPD is

tobacco smoke (including second-hand or passive exposure). Other risk factors include: 1. Indoor air pollution (such as solid fuel used for cooking and heating) 2. Outdoor air pollution 3. Occupational dusts and chemicals (vapors, irritants, and fumes) 4. Frequent lower respiratory infections during childhood

COPD Diagnosis

COPD is confirmed by a simple diagnostic test called

"spirometry" COPD develops slowly, it is frequently diagnosed in people aged 40 or older COPD is not curable Various forms of treatment can help control its symptoms and increase quality of life for people with the illness. For example, medicines that help dilate major air passages of the lungs can improve shortness of breath

NON-COMMUNICABLE DISEASE GOVERNMENT INITIATIVES & POLICIES

Introduction

National policies in sectors other than health have a

major bearing on the risk factors for NCD The health sector however plays a role in advocacy and partnering with other sectors to effect change Actions must also utilise a life-course approach, starting with maternal health and pre-natal nutrition, pregnancy outcomes, exclusive breastfeeding, and child and adolescent health, reaches children at schools, adults at workplaces and other settings, and the elderly; and encourages a healthy diet and regular physical activity from young into old age

Introduction

In line with the seven strategic action areas contained

in the Western Pacific Regional Approach to Operationalise the Global Action Plan for the Prevention and Control of NCD, Malaysias own framework for operationalising the National Strategic Plan for Non-Communicable Diseases will be based on the following:

Seven Strategies 1. Prevention and Promotion 2. Clinical Management 3. Increasing Patient Compliance

Introduction

Diseases will be based on the following:

Seven Strategies 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

 A great number of stakeholders have to be actively

involved, both in creating policies and legislations to create a health promoting built environment and also in implementing the programmes to prevent and control NCD in Malaysia:
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Ministry of Health Private clinics, private hospitals and all health care facilities Departments and ministries Ministry of Education Ministry of Higher Education Ministry of Youth and Sports Ministry of Agriculture and Agro-based Industry Ministry of Transport Ministry of Information Ministry of Domestic Trade, Co-operatives and Consumerism

Strategy 1: Prevention & Promotion

Media and social marketing is important to promote

healthy lifestyles and to increase knowledge and awareness of NCD risk factors will be strengthened Few workplace-based and community-based demonstration programmes to empower individuals at high risk or with chronic diseases to develop health literacy, take on self-care responsibilities and become a resource for themselves and others in disease prevention and management will be further expanded

Strategy 1: Prevention & Promotion

NCD prevention and control interventions will be

incorporated into the Healthy Settings approach; this will include expanding the school health services to include nutrition and exercise promotion, cardiovascular risk and early intervention

Strategy 1: Prevention & Promotion

Key Activities 1. Strengthening existing content & creating new content for health promotion addressing the main diabetes (NCD) risk factors; unhealthy eating and physical inactivity (other NCD risk factors will also be included). The main messages are: I. Increase the awareness of overweight and obesity as a major public health threat II. Inculcate healthy eating habits among Malaysians III. Inculcate active living (physical activity) / exercise among Malaysians

Strategy 1: Prevention & Promotion

Key Activities IV. Increase the awareness of other NCD risk factors and importance of early and regular screenings (family history, smoking status, mental stress, alcohol abuse, dyslipidaemia, hypertension and elevated blood glucose) V. Increase the awareness of Malaysians on total cardiovascular risks 2. Intensifying media campaigns using television, radio and printed media, and use of new approaches (e.g. via social networking on the internet)

Strategy 1: Prevention & Promotion

Key Activities 3. Strengthening of the School Health programmes to include a component involving the family and community, in both health education and healthpromoting activities, with emphasis on: I. Increase and re-orient physical education II. Promote extracurricular physical activity III. Improve access to healthy food at schools IV. Increase barrier to unhealthy food at schools V. School-based NCD risk factor screening & intervention

Strategy 1: Prevention & Promotion

Key Activities IV. School-based NCD risk factor screening & intervention. This includes strict enforcement of existing healthy food policies and provisions at schools and school canteens. The Ministry of Health needs to revise existing and develop new guidelines, manuals and training modules for all of the activities

Strategy 1: Prevention & Promotion

Key Activities 4. Strengthening of the Workplace-based Health programmes, in both health education and healthpromoting activities, with emphasis on: I. Promoting physical activity II. Improve access to healthy food & increase barrier to unhealthy food III. Workplace-based NCD risk factor screening & intervention

Strategy 1: Prevention & Promotion

Key Activities 5. Strengthening of the Community-based Health programmes, in both health education and healthpromoting activities, with emphasis on: I. Promoting physical activity II. Improve access to healthy food & increase barrier to unhealthy food (e.g. Kafeteria Sihat and Pasaraya Sihat, or Healthy Cafeteria and Healthy Supermarket) III. Community-based NCD risk factor screening & intervention

Strategy 2: Clinical Management

This involves strengthening health service delivery

system, at primary and secondary levels, clinical practice guidelines and evidence-based decision support tools to ensure the appropriate and timely screening, diagnosis and treatment of chronic diseases

Strategy 2: Clinical Management

Key Activities 1. To ensure that all health facilities are equipped with the minimum clinical equipments and tools for assessment and management of diabetes, obesity and other NCD risk factors, as specified in SOPs. This includes increasing the coverage of laboratory investigations 2. Create a system for supervision of all medical practitioners in appropriate and quality clinical management (diabetes and its related complications), to ensure in-line with CPGs and related

Strategy 2: Clinical Management

Key Activities 3. Increase the usage of CPGs and SOPs by continuous professional development for all health care personnel involved with patient care. And increase the availability and ease of use of CPGs and SOPs by creating different formats 4. Reinforcement of importance of screening for diabetes-related complications: I. Screening done as per CPG II. Regular training and reinforcement of messages for all health practitioners

Strategy 2: Clinical Management

Key Activities 5. Strengthen obesity (and other NCD risk factors) intervention programmes at all levels of care 6. Strengthening & expansion of the rehabilitation services of diabetes related complications (e.g. stroke, amputees) at all levels (including community level)

Strategy 3: Increasing Patients Compliance

Self-management programmes have been shown to

reduce the severity of symptoms, improve confidence, resourcefulness and self-efficacy of patients with chronic disease It should therefore be advocated and supported through effective patient education This requires effective communication skills, behavioural change techniques, patient education and counselling skills of health care professionals and workers to care for patients with NCD.

Strategy 3: Increasing Patients Compliance

Key Activities 1. Development of inter-personal health education programmes at all MOH health care facilities 2. Development of self-guided intervention packages to help patients with NCD and NCD risk factors and their families to monitor and manage their disease or condition

Strategy 3: Increasing Patients Compliance

Key Activities 3. Ensure that all health facilities have an NCD Resource Centre, staffed by appropriately trained diabetes educators or suitably trained health care personnel, and equipped with equipments, tools and IEC materials as specified in SOP guidelines 4. Specifically for diabetes, making available subsidised glucostrips for Self Monitoring of Blood Glucose (SMBG)

Strategy 4: Action With NGOs & Other Stakeholders

Population-based lifestyle interventions require a

whole-of-society response Political and community leadership, partnerships and community mobilisation are essential to ensuring acceptance and popular support for NCD prevention and control. Resources for prevention and control are limited; partnerships and collaboration can facilitate resource leveraging to augment national health budgets Furthermore, policy and population based interventions require the cooperation and acceptance of society

Strategy 4: Action With NGOs & Other Stakeholders

Key Activities 1. Foster multi-sectoral partnerships and encourage stakeholder participation in developing, implementing and evaluating NCD prevention and control interventions 2. Develop and implement an advocacy campaign that is consistent with and supportive of the national action plan for NCD prevention and control

Strategy 4: Action With NGOs & Other Stakeholders

Key Activities 3. Actively advocate to national, state, district and local community leaders, and other partners (e.g. industries), to enhance their awareness of the magnitude of the NCD burden, to engender their commitment for instituting effective measures to prevent and control chronic diseases and their risk factors, and to ensure the inclusion of relevant strategies into policies and agreements 4. Coordination with all relevant stakeholders for the implementation of programmes and activities at the grass root level, which includes health camps,

Strategy 4: Action With NGOs & Other Stakeholders

Key Activities 4. Coordination with all relevant stakeholders for the implementation of programmes and activities at the grass root level, which includes health camps, seminars, workshops, talks and other training programmes 5. Identification and involvement of all relevant stakeholders in strengthening Communitybased health programmes in the promotion of healthy diet and physical activity

Strategy 4: Action With NGOs & Other Stakeholders

Key Activities 6. Continue to collaborate with the food industries (including food technologists & retailers) to increase the production and promotion of low & low sugar foods 7. Intensify physical activity programmes in the community e.g. brisk walking & exercise groups 8. Continue partnerships with the media & advertising industries to promote the messages of healthy eating & being active together with factual information on obesity and weight reduction. This includes engaging presenters/hosts and celebrities to use the celebrity status as role models

Strategy 5: Monitoring, Research & Surveillance

Research into the economic costs of NCD, the cost

effectiveness and cost-benefits of prevention strategies, and other health economics analyses supply powerful arguments for instituting policy and regulatory interventions to reduce NCD burden Prevalence studies for both risk factors and chronic disease conditions provide critical information on which to base priority setting and the selection of specific population and clinical interventions for particular communities and target groups

Strategy 5: Monitoring, Research & Surveillance

Surveillance data, collected over time, also give an

indication of the effectiveness of interventions on population risk factor and disease end-points Evaluation studies complement surveillance data by examining efficacy, cost-effectiveness and impact more thoroughly Behavioral studies and applied research, including community-based participatory research, result in greater understanding of the behavioral change process, which is fundamental to prevention

Strategy 5: Monitoring, Research & Surveillance

Medical studies offer the evidence base for clinical

approaches to disease management For greatest utility, research communities and countries should utilize standardized methodologies, instruments, indicators, to permit comparisons and broad applicability of lessons learned

Strategy 5: Monitoring, Research & Surveillance

Key Activities Implement a system to monitor degree of control and quality of management of diabetes patients at health care facilities Nation-wide implementation of Behavioral Surveillance Survey (BSS) on healthy eating habits, level of physical activity and exercise of Malaysians. BSS will form one of the two backbones for the monitoring and evaluation on the progress and effectiveness of NSPNCD

Strategy 5: Monitoring, Research & Surveillance

Key Activities Nation-wide implementation of NCD Risk Factor Surveillance, looking at selected NCD and NCD risk factors amongst Malaysians. Together with the BSS, it will form the mechanism for the monitoring and evaluation on the progress and effectiveness of NSPNCD Nation-wide implementation of a National Diabetes Registry

Strategy 5: Monitoring, Research & Surveillance

Key Activities Encourage research in Diabetes, Obesity and NCD risk factors, including aspects of: I. Health economics of population-based interventions II. Novel approaches for behavioral modifications III. Novel approaches for clinical management

Strategy 6: Capacity Building

There is a need to continually improve the skills,

knowledge and attitude of all health care personnel, both in primary care and hospital settings, to deal with the challenge of chronic disease management This can be done through continuous professional development training courses, conducted especially at the local level Availability of trained paramedics is critical to support successful implementation of NCD management program

Strategy 6: Capacity Building

There should be a constant effort to increase the

number of nurses and assistant medical officers especially trained in the management of NCD In addition, members of other stakeholders involved will also need to be adequately trained to enable them to become active partners with the MOH and actively advocate for the prevention and control of NCD in the various settings of schools, workplaces and the community

Strategy 6: Capacity Building

Key Activity 1. Training of all categories of health care staff for health promotion and prevention the following areas: I. Healthy eating II. Staying active (physical activity / exercise) III. Obesity IV. Smoking cessation V. Screening of NCD risk factors (including total cardiovascular risks)

Strategy 6: Capacity Building

Key Activity 2. Training of teachers and members of ParentsTeachers Association to raise awareness of the issue of increasing obesity and other NCD risk factors in children (under School Health Programme), with emphasis on: I. NCD risk factors (in particular obesity) II. Prevention and management of childhood obesity III. Healthy eating & physical activity / exercise

Strategy 6: Capacity Building

Key Activity This includes additional training for implementation of school-based programs for NCD risk factor management MOH is responsible for producing the necessary guidelines, manuals and training modules

Strategy 6: Capacity Building

Key Activity 3. Training of members of the community in healthy eating, physical activity and exercise, obesity and total cardiovascular risk (NCD risk factors)
I. Panel Penasihat Kesihatan could be used as the starting point II. NGOs will also feature prominently III. To identify core group of trainers (can be members of the community and NGOs) IV. This includes additional training for implementation of community-based programs for NCD risk factor management V. MOH is responsible for producing the necessary guidelines, manuals and training modules

Strategy 6: Capacity Building

Key Activity 4. Training of employers to raise awareness on prevention and control of diabetes and obesity (and other NCD risk factors), with emphasis on: I. Economics of a healthy workforce II. Prevention and management of obesity (and other NCD risk factors) This includes additional training for implementation of work-place based programmes for NCD risk factor management MOH is responsible for producing the necessary guidelines, manuals and training modules

Strategy 6: Capacity Building

Key Activity 5. Conduct courses for media workers, particularly copywriters and TV/radio hosts to promote health and counter misinformation Core group of trainers to be identified MOH is responsible for producing the necessary guidelines, manuals and training modules

Strategy 7: Policy & Regulatory Interventions

Malaysia has in place many policy recommendations

relevant to NCD prevention and control as listed below: I. National Nutrition Policy and the National Plan of Action for Nutrition of Malaysia (2006-2015) II. Food Act 1983 and Food Regulations 1985 III. National Sports Policy IV. Agriculture Policy V. Strategy for the Prevention of Obesity - Malaysia

Strategy 7: Policy & Regulatory Interventions

Malaysia has in place many policy recommendations

relevant to NCD prevention and control as listed:
I. National Nutrition Policy and the National Plan of Action for Nutrition of Malaysia (2006-2015) II. Food Act 1983 and Food Regulations 1985 III. National Sports Policy IV. Agriculture Policy V. Strategy for the Prevention of Obesity Malaysia VI. National Adolescent Policy VII. National Policy for Elderly VIII. National Health Policy for Elderly IX. Convention on the Rights of the Child X. National Policy for Women XI. National Youth Policy XII. Education Act 1996

Strategy 7: Policy & Regulatory Interventions

Opportunities to merge NCD prevention and control

into related health and non-health policy areas, such as those that address urban development (e.g. Healthy Cities), poverty alleviation, and sustainable development needs to be identified and utilized There is also a need to establish economic policies that reinforce healthy lifestyle choices through pricing, taxation, subsidies and other market incentives

Strategy 7: Policy & Regulatory Interventions

Key Activities Adopt and fully implement existing policy recommendations relevant to NCD prevention and control Development of a National Physical Activity Policy together with the Ministry of Youth and Sports. This may involve reviewing the National Sports Policy (1988) to meet the objectives of NSP NCD Incorporate nutrition and physical activity policy statements and programmes in the development plans of all relevant ministries and agencies

Strategy 7: Policy & Regulatory Interventions

Key Activities Promotion of availability of fresh local fruits and vegetables, via subsidies for farmers, and to hold more regular fairs (e.g. Malaysian Agriculture, Horticulture & Agrotourism (MAHA) show in all states) To continue to regulate and decrease the content of salt and sugar in all processed food and drink, via regulations and self-regulation by industries. To increase the availability of facilities in the community to promote physical activity & exercise in a safe environment, e.g. public parks, public sports complexes, jogging, cycling path, public gymnasium

Strategy 7: Policy & Regulatory Interventions

Key Activities Expansion of an efficient public transport system throughout Malaysia, and policies to limit the use of private transportation in the city centres to promote the use of public transport which will encourage physical activity Expansion of the compulsory regular NCD risk factor screening for all employees age 40 years an above

Roles Of Key Government Ministries

They all have to be actively involved, both in creating

policies and legislations to create a health promoting built environment and also in implementing the programmes to prevent and control NCD in Malaysia

THANK YOU