ECOSYSTEM APPROACH TO DENGUE CONTROLPETALING DISTRICT

DR.MOHAMED PAID YUSOFPUBLIC HEALTH MEDICINE SPECIALIST

PROBLEM: DENGUE

▪ Dengue is a common tropical disease affecting many different countriesglobally and is a major public health burden worldwide.

▪ Malaysia is among those countries that are worse affected, withrecorded cases rising from 32 cases per 100,000 population in 2000 to361 cases per 100,000 population in 2014.

▪ Until June 2016, Selangor state was the major contributor to the nationalburden with more than half of the cases recorded belonging to Selangor.

DENGUE SITUATION IN MALAYSIA, UP TO EPIDEMIOLOGY WEEK 22, 2016

State Case DeathPerlis 83 1Kedah 356 1Penang 1,765 10Perak 1,945 4Selangor 27,166 44Federal Territory of Kuala Lumpur & Putrajaya 3,712 5Negeri Sembilan 1,358 10Melaka 1,029 1Johor 6,857 10Pahang 1,231 6Terengganu 1,519 13Kelantan 1,064 1Sarawak 1,216 4Sabah 1,296 1Labuan 3 0Malaysia 50,600 111

DENGUE CONTROL

▪ Dengue control programmes consist of 3 major components;▪ Vector control,▪ Monitoring and surveillance▪ Community participation and enforcement

▪ Monitoring and surveillance has led to better reporting of the disease,more widespread public knowledge an early treatment-seekingbehaviour.

▪ Community participation and community education campaigns andenforcement via premise inspections for mosquito breeding sites havebeen introduced to increase dengue awareness and preventive efforts

DENGUE CONTROL

▪ However, the efforts has not diminished the mosquitopopulation nor disease burden.

▪ Most of the dengue cases reported were mainly fromthe urbanites where factors such as high densitypopulation and rapid development favour denguetransmission.

THE CHALLENGES OF DENGUE CONTROL PROGRAMME IN PETALING DISTRICT

▪ Mainly due to the effect of urbanisation and rapiddevelopment which includes:▪ Indiscriminate dumping of garbage results from poor garbage

maintenance particularly in the low to medium cost apartments.▪ Construction site acts as a breeding ground for the mosquitoes.▪ Difficulty in starting and sustaining community mobilization

programme among the community.▪ Intermittent rain and hot weather that promote good

environment for mosquitoes breeding.

SETTING: PETALING DISTRICT

▪ Petaling District is a district located in the state of Selangorin Malaysia.

▪ Middle of Klang Valley.

▪ Hub of Malaysian industries and commerce.

▪ Encompasses an area of 484.32 km², population in 20141,928,900; Malays (51%); China (35%); India (12%); Others (2%)and a population density of 3,700/km².

▪ Highly urbanized district Divided and delegated into thethree local municipalities:▪ Majlis Bandaraya Shah Alam; Majlis Bandaraya Petaling

Jaya and Majlis Perbandaran Subang Jaya

BURDEN OF DISEASE▪ The dengue incidence in Petaling District is almost four times that of the national figure,

which is 1,205 cases per 100,000 population.

▪ The dengue cases also continued to rise exponentially in 2014 onwards as shown inFigure 1.

0

5000

10000

15000

20000

25000

30000

2011 2012 2013 2014 2015

Denggi Denggi Berdarah Mati

Dengue Fever

Dengue Hemorrhagic Fever

Figure 1: Number of dengue cases from 2011 to 2015 in Petaling district.

BURDEN OF DISEASE▪ In comparison with all the health districts in Malaysia, Petaling district was at the top

rank with 233 case reported in epid week 22

0 50 100 150 200 250

Petaling

Hulu Langat

Johor Bahru

Klang

Gombak

Sibu

Kepong

Sepang

Seremban

Titiwangsa

Lembah Pantai

Hulu Selangor

Kuantan

Kinta

Cheras

Total Case

Figure 2 : Top 15 Dengue Cases reported according to district in Malaysia, Epid week 22, 2016.

APPROACH PRIOR TO 2015….

▪ Case based approach

▪ Control activities carried out were according to number of casesnotified to the District Health Office.

▪ Problem:

▪ Coverage was; ScatteredAccording to casesGeographically limited.

▪ There were no preventive measures in place.▪ Successful broad scale application was a challenge for the health office.▪ Approach to dengue control was more reactive than preventive.

“GREATER EMPHASIS SHOULD BE PLACED ON PROACTIVE STRATEGIES THAT AIM TO PREVENT,

DIMINISH, OR ELIMINATE TRANSMISSION”

ACHEE ET AL, CRITICAL ASSESSMENT OF VECTOR CONTROL FOR DENGUE PREVENTION

2015

AFTER 2015…

▪ The ecosystem approach was introduced in Petaling District.▪ Novel approach to combat dengue due to the rising incidence of the

disease.▪ Petaling was the sole health office that applied this system in a district

wide scale.▪ Under this approach, the district was divided into 17 ecosystems in its

3 town councils:i. Shah Alam Town Council - 5 ecosystemsii. Petaling Jaya Town Council - 7 ecosystemsiii. Subang Jaya Town Council - 5 ecosystems

ECOSYSTEM APPROACH TO DENGUE CONTROL

▪ Each ecosystem is further divided into localities. District of Petaling has2,023 localities and each ecosystem has different number of localities.

▪ For example, ecosystem 1 has 138 localities and ecosystem 2 has 85localities.

PBT Ecosystem No. of locality

MBSA 5 702

MBPJ 7 538

MPSJ 5 783

Total 17 2,023

LOCALITIES IN SHAH ALAM TOWN COUNCIL

ECO 4 (171 Localities)ECO 5 (260 Localities)

ECO 1 (138 Localities)

ECO 2 (85 Localities)

ECO 3 (47 Localities)

ECOSYSTEM APPROACH TO DENGUE CONTROL

▪ Each ecosystem is placed under an Assistant Officer ofEnvironmental Health▪ Who plans and coordinates prevention and control activities▪ Need to be familiar and well equipped with knowledge of their

respective ecosystem▪ Identify problematic localities.

▪ Each officer is supported by a team of Public Health Assistantsand a General Assistant

ECOSYSTEM APPROACH TO DENGUE CONTROL

▪ This decentralized, community based approach centres aroundenvironmental management based on risk assessment.

▪ The risk assessment for each ecosystem identifies the localityat risk by spotting conditions such as;▪ Open land▪ Abandoned house▪ Blocked drainage▪ Common public area▪ Construction sites▪ Stores

ECOSYSTEM APPROACH: MAIN ACTIVITIES

▪ The main activities in the ecosystem approach focuses on prevention,rather than control.

▪ Preventive activities include;▪ Destruction of breeding sites▪ Larvaciding▪ Ultra-low volume fogging▪ Community clean up▪ Health education and awareness

▪ The planned preventive activities involve multiple agencies includinghealth authorities, town council, enforcement officers, volunteers, non-governmental organizations and community in the specific locality.

ECOSYSTEM APPROACH: RELEVANT CHANGES

0

200

400

600

800

1000

1200

1400

1600

1800

2000

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53

2014 2015 2016

Figure 3: Number of dengue cases notification from 2014 to 2016 according to Epidemiological Week, Petaling district, Selangor

ECOSYSTEM APPROACH: RELEVANT CHANGES

▪ Vector control teams provided personalized and comprehensive care according to ecosystem needs▪ Expected to know the environment, community and its risks well enough

to coordinate activities. ▪ Encourages and improves community participation which is vital for the

battle against dengue.

▪ There was a shift away from a standard nationwide ‘top-down’ approach to ▪ Risk based ▪ Multi-agency and community partnership▪ To resolve environmental sanitation and vector control problems.

LESSONS LEARNT

▪ Preventive and control activities should be flexible and tailoredaccording to the geographical suitability.

▪ Despite large geographical and different municipalities,sufficient human resource and good logistics support makes itpossible to implement the ecosystem approach.

▪ Ideally, each ecosystem has an officer in charge with adequateassistants to carry out respective preventive and controlactivities. However, due to limited staffing, roles are sometimesinterchangeable which may increase workload.

LESSONS LEARNT

▪ Dengue control is complex, due to factors external to thehealth sector, which are important measures in improvingdisease and dispersal of its vector.

▪ The effectiveness of an ecosystem approach can also bemeasured through peoples’ knowledge, attitude andwillingness to participate in preventive programmes.▪ An overall feedback mechanism on the implemented

programme could also be established to gauge effectivenessof the programme.

CONCLUSION

▪ Many of the conventional methods to dengue controlare not applicable in high endemic areas

▪ The approach to dengue control should be flexible andtailored according to geographical suitability.

▪ Therefore, the ecosystem approach to dengue control ishighly recommended in these areas.