NCD SURVEILLANCE IN PUBLIC HEALTH

Differences between CD & NCD surveillance

Definition
Systematic ongoing collection,
collation, & analysis of data &
the timely dissemination of
information to those who need
to know so that action can be
taken”(WHO)
Process of NCD Surveillance
Objective Surveillance
• Baseline rate of disease & detect
increases
• Estimate magnitude of health problem
• Determine geographical distribution
• Understand natural history of diseases
• Generate hypotheses, stimulate
research
• Evaluate control measures
• Monitor changes in chronic disease
presentation / infectious agents
• Detect changes in health practices
• Facilitate planning

Components of NCD Surveillance

Population Data
1. National surveillance 1. Health departments & // organizations
2. Specific to high-risk groups • Collect data
• Occupation • Use forms for paper-based, fax / emailed reports
• Health status (e.g. pregnancy • Mine data from electronic records (data mining) e.g: HIS,
clinics) vital statistics
• Geographic area 2. Laboratory
• Testing
• Diagnosis

Types of Surveillance
for NCD
1. Passive
Simplified flowchart for a generic surveillance system • “passive” initial
report for public
health authorities
• Most common type
of data collection
------------------------------
2. Active
• Action required by
local public health
authority to collect
data
• Requires more
resources than
passive surveillance

Types of Surveillance System

Bias in NCD Surveillance
Selection
• Degree to which surveillance
data do not represent the
population / geographical
areas
• Method of assessing the
population affects the
information gathered
• Point of medical care vs. lack
of resources / availability to
access case
• Physicians / organizations
which are easily recruited vs.
those that are representative
Information
• Degree to which the data
obtained do not accurately
reflects the true values /
measures
• Missing data (especially those
important to the topic).
• Example: “smoking” field is
blank especially among
smokers who may not want to
admit to smoke
• Question / field is open to
interpretation.
• Example: “Diagnosis” could
be from the initial doctor, the
hospital discharge records,
the underlying cause of
disease / listed as cause of
death.
Population-based Sentinel
• Systems accepts data • Surveillance on a selected subset of potential
from all providers & // sources
laboratory in a country • Collection of data from a limited number of sites
• Sometimes involves a • Can be passive, active / combined
legal mandate for • Sites can be chosen to be representative of a
providers & laboratories population of interest
to report • Clinics, Hospitals, Laboratories, Individual providers
• Reporting forms are • Representative samples of cases is highly
standardized by health recommended
districts / nationally • Useful if there is no existing surveillance system / if
• Reporting accomplished one has been disrupted
through local collection, • Can be expensive
passed through district • Difficult to ensure that selected sites are
level to the national representative of a larger population
level • More information on risk factors can be collected
• Example: demographic surveillance system
Examples of NCD Surveillance
• Global Tobacco Surveillance System (GTSS)
• Data collected through four surveys
 Global Youth Tobacco Survey (GYTS)
 Global School Personnel Survey (GSPS)
 Global Health Professions Student Survey (GHPSS)
 Global Adults Tobacco Survey (GATS)
1
 METABOLIC SYNDROME
Definition Risk factors
• The metabolic syndrome is a combination of medical disorders that, when occurring together, increase the 1. Modifiable risk factors (lifestyle
risk of developing cardiovascular disease & diabetes. factors)
• The metabolic syndrome is a cluster of heart attack risk factors: diabetes & raised fasting plasma glucose, • poor diet
abdominal obesity, high cholesterol & high blood pressure. • insufficient physical activity
• tobacco use & smoking
• psychological factors (eg:
Diagnosing Metabolic Syndrome
psychosocial stress)
Harmonized • excessive alcohol consumption
Risk Factors WHO (1999) ATPIII (2001) IDF (2005) AHA (2005) 2. Non-modifiable risk factors
(2009)
• age
BMI ≥ • gender
WC
Obesity (BMI) / 30kg/m2 WC [Asian] WC [Asian] • ethnicity
[Caucasian] M ≥ 102 cm
abdominal obesity and/or WHR M ≥ 90cm M ≥ 90 cm • family history
M ≥ 102 cm F ≥ 88 cm
(WC) >0.9 [M], F ≥ 80cm F ≥ 80 cm 3. Wider determinants of health
F ≥ 88 cm
>0.85 [F] • safe physical environment
• open green spaces
≥ 130/85
High BP ≥ 140/90 ≥ 130/85 ≥130/85 mm ≥ 130/85 mm • access to education
mm Hg / on
(systolic/diastolic) mmHg / on Rx mmHg Hg / on Rx Hg / on Rx • poverty
Rx
• being employed
High FPG (mmol/l) DM, IGT / IR ≥ 6.1 / DM ≥ 5.6 / DM ≥ 5.6 / DM ≥ 5.6 / DM • housing area
• food production & availability
≥20µg/min /
Microalbuminuria Not used Not used Not used Not used
ACR ≥30mg/g
Prevention
Elevated TG ≥1.7 mmol/l ≥1.7 mmol/l ≥1.7 mmol/l ≥1.7 mmol/l ≥1.7 mmol/l Two approaches;
1. Population-wide approach
< 0.9 mmol/L < 1.03 mmol/l < 1.03 < 1.03 mmol/l • Comprehensive tobacco control
<1.0 mmol/l [M]
Reduced HDL-C [M] [M] mmol/l [M] [M] policies
<1.3 [F]
<1.0 [F] < 1.29 [F] < 1.29 [F] < 1.29 [F] • Fat, sugar & salt tax
DM, IGT / IR + • Building walking & cycle paths to
WC + 2 / increase physical activity
Metabolic syndrome any 2 / more At least 3 RF At least 3 RF At least 3 RF
more RF • Strategies to reduce harmful use
RF
of alcohol
Voluntary Global Targets / WHO Responses Objectives • Provide healthy school meals to
children (kantin sihat)
WHO 2. Individual approach
• A global mechanisms to • Secondary prevention of CVDs in
reduce the avoidable NCD those with established disease,
including a “Global action such as diabetes. Aspirin, beta-
plan for the prevention & blocker, ACEi, statins are
control of NCDs 2013-2020” necessary.
was introduced in 2013.
• Aims to reduce the number *These approaches can be combined
of premature deaths from
NCDs by 25% by 2025
through 9 voluntary global
targets

Malaysian Strategies: NSP-NCD

Strategies;
1. Prevention & Promotion
2. Clinical Management
3. Increasing Patient Compliance
4. Action with NGOs, Professional Bodies & Other Stakeholders
5. Monitoring, Research & Surveillance
6. Capacity Building
7. Policy & Regulatory Interventions

Malaysian Strategies: NSP-NCD

Main objective;
 To address NCD risk factors effectively in different setting outside of a
health clinic, using obesity as the main entry point for NCD risk factor
intervention
Specific objectives
 Increase coverage of NCD risk factor screening to detect individuals with
NCD risk factors at an early stage;
 Implement NCD risk factor intervention among at-risk individuals in three
different settings i.e. community, work-place & schools;
 Implementation in an on-going & sustainable basis;
 Reduce the prevalence of NCD risk factor in Malaysia;
 Reduce the burden of NCD in Malaysia.
2
 CARDIOVASCULAR DISEASES PREVENTION & CONTROL
Def: A group of disorders of the heart & WHO’s
blood vessels
Include;
• Coronary heart disease
• Cerebrovascular disease
• Peripheral artery disease
• Rheumatic heart disease
• Congenital heart disease
• Deep vein thrombosis & pulmonary
embolism

Risk factors
• Non modifiable risk
• Modifiable risk
 Unhealthy diet
 Physical inactivity
 Tobacco use
 Harmful use of alcohol

Other way of classifying risk factors

Other way of classifying risk factors

WHO Responses Objectives

3
 ROAD TRAFFIC INJURIES
Def: Road traffic accident injuries are defined as fatal / non-fatal injuries incurred as the result of road traffic crashes. The crash is defined as a collision /
incidence that may / may not lead to injury, occurring on a public road & involving at least one moving vehicle (WHO, 2002).

Magnitude & Impact

 Worldwide, over 1.24 million people die on the road each year, with 20 to 50
million suffering from non-fatal injuries (Peden et al., 2004).
 It is the ninth leading cause of disability adjusted life years (DALYs) lost
worldwide (Binder & Runge, 2002)
 Road traffic injuries are the leading cause of death among young people, aged
15–29 years & 91% of the world's fatalities on the roads occur in low-income &
middle-income countries (Peden et al., 2004).
 It is estimated that road traffic crashes costs (Peden et al., 2004) US$ 518 billion
globally.
 Road traffic injuries put significant financial strain on families. Many families are
driven into poverty by the cost of prolonged medical care, the loss of a family
breadwinner / the extra funds needed to care for people with disabilities.
 Road crash survivors, their families, friends & other caregivers often suffer
adverse social, physical & psychological effects.
In Malaysia:
 Traffic accidents in Malaysia have been increasing at the average rate of 9.7%
per annum over the last three decades.
 Compared to the earlier days, total number of road accidents had increased from
24,581 cases in 1974 to 328,264 cases in 2005, reaching more than 135%
increase of accident cases over 30 years (Mustafa, 2006).
 According to the Ministry of Health, the incidence of motor vehicle accidents in
the year 1985 was 225 for every 10,000 vehicles to rising to 250/10000 in 1995
(Kareem, 2003).
 The number of traffic accidents in 2007 almost doubled as compared in1997.
 60 % of total fatalities involved motorcyclists.
 Malaysia is ranked 46th of 172 countries with regards to occurrence of deaths in
registered vehicles to road accidents (WHO, 2009).
 According to WHO Global Status Report on Road Safety, Malaysian road users
are ranked as the worst in South East Asia with an average of 23.8 deaths per
100,000 population over the span of 12 years, while research by MIROS has
concluded that speeding is the cause for 60 per cent for all accidents in the
country.
 In addition, Malaysia is third in road fatalities per billion kilometres with risk of
dying in a road accident at 17.7 deaths. South Korea is the highest with 20.1
deaths followed by the Czech Republic with 19.4

Fundamental Concepts Of Risk & Prevention PREVENTION - The 3 ‘E’s

 The Haddon Matrix is the most commonly used
paradigm in the injury prevention field.
 Developed by William Haddon in 1970, the matrix
looks at factors related to personal attributes,
vector / agent attributes, & environmental
attributes before, during & after an injury /
death. By utilizing this framework, one can then
think about evaluating the relative importance of
different factors & design interventions
 Interaction of:-
 three factors: human, vehicle & environment
 three phases of crash event: pre-crash, crash
& post-crash
 Result:
 nine-cell matrix models
 each cell allowing opportunities for
intervention to reduce road crash injury
Education:
 Road Safety Education in Schools - Road safety education is now taught until primary 4 as
part of the Bahasa Malaysia subject which will be extended to primary 6 by 2010. Other
measures in schools are traffic wardens, road safety clubs, etc.
 Media Campaign on TV, Radio, Newspapers & Cinemas - Media campaign via TV, Radio,
Newspapers & Cinemas while Road safety radio commercials given free slots during prime
time on all radio channels – 30 seconds for every ½ hour.
Engineering: Altering the environment to reduce risk & chance taking
 Safer cars - High-mounted brake lights; some direct sensors of the rate of closure with the
front vehicle.Air bags - From 1990 to 2000; the U.S. National Highway Traffic Safety
Administration agency estimated more than 6,377 lives saved & countless injuries
prevented.
 Road design - Studies shown that causes to most of the accident is because of the drivers
themselves.
o Throughout the MIROS study period from 2007 through 2010, most accidents occur in fair
weather & during day time.
o Speed-breakers are designed to be driven over at a predetermined comfortable speed,
while causing exceeding discomfort at higher speeds. The reduction in average vehicular
speed significantly improves the safety of people in the neighboring areas.
o For example, a before & after study in Ghana found that speed humps reduced casualty
crash frequencies by 37.5%, fatal crashes by 46% & pedestrian crashes by 72% (Francis &
Afukaar, 2010).
Emergency responses:
o MERS 999 is an initiative by the Malaysian Government for computerised emergency call
taking & dispatching.
o Under its single platform, the country’s five emergency service providers- the Police, Fire
& Rescue Department, Ambulances/Hospitals, Civil Defense & Maritime Enforcement
o An operator team will be set up to answer emergency calls within 20 seconds; the current
response time averages 30 seconds
4
 ROAD TRAFFIC INJURIES cont…
PREVENTION - The 3 ‘E’s (..cont)
Enforcement:
 National speed limit for federal road is 90km/hour.
 The default National Speed Limit on Malaysian
 expressways is 110 km/h (70 mph), but in certain areas a lower speed limit (such as 90
km/h (55 mph) / 80 km/h (50 mph)) is applied, especially in large urban areas,
crosswinds, heavy traffic & in dangerous mountainous routes & 60 km/h is applied 1 km
before the toll plaza. Speed traps are also deployed at many places.
 Photo radar (controversial)
 Wearing of seat belt, motorcycle helmet & daytime lights are mandatory
 Driving under the influence of drugs & alcohol is an offence. Police & National Anti
Narcotics Agency has carried out regular checked to the suspected drivers.
 The Land Public Transport Commission (SPAD) together with the Road Transport
Department (JPJ) & the police conducts an integrated road safety operation.
 The operation would be divided into three focus areas of monitoring, with the
enforcement agencies concentrating on inspection of permits of public transportation
vehicles as well as bus ticket touts.
 JPJ’s focus is to inspect the technical aspects of vehicles around depots & bus terminals
throughout the peninsula while the police would conduct checks on expressways,
federal & state roads.

Five pillars for a Safe Systems approach:

 Pillar One: Building Management Capacity
o Creation of multi-sectoral partnerships & designation of lead agencies with the capacity to develop national road safety strategies, plans &
targets, supported by data collection & evidential research to assess countermeasure design & monitor implementation & effectiveness.
 Pillar Two: Influencing Road Design & Network Management
o Using road infrastructure assessment rating & improved design to raise the inherent safety of road networks for the benefit of all road users,
especially the most vulnerable.
o International Road Assessment Programme (iRAP) -a non-profit organisation dedicated to saving lives through safer roads by inspecting high-
risk roads & developing Star Ratings & Safer Roads Investment Plans.
o Road Assessment Programmes (RAP) are now active in more than 50 countries, including Mexico, China, Vietnam, Australia, New Zealand, India
& Malaysia.
 Pillar Three: Influencing Vehicle Safety Design –
o Global deployment of improved vehicle safety technologies, & accelerate the uptake of new technologies.
o Vehicle manufacturers have a responsibility to produce safe cars. They must meet this obligation in every market.
o All cars should be engineered for safety, & basic safety measures like air bags should no longer be considered optional extras.
o Euro NCAP provides motoring consumers with a realistic & independent assessment of the safety performance of some cars sold in Europe. This
acts as an incentive for manufacturers to improve the safety of their cars.
 Pillar Four: Influencing Road User Behaviour
o Through sustained enforcement of road traffic rules combined with public awareness/education activities that will raise compliance with
regulations that reduce the impact of the key risk factors (non-use of seat belts & helmets, drink driving & speeding).
 Pillar Five: Improving Post Crash Care
o To increase responsiveness to emergencies & improve the ability of health systems to provide appropriate emergency treatment & longer term
rehabilitation. Studies of the effect of improving organisation & planning of trauma care in high-income countries have consistently shown
survival gains of between 8% & 50%.

5
Definition: is the intentional use of physical force / power,
threatened / actual, against oneself, another person, /
against a group / community, which either results in / has a
high likelihood of resulting in injury, death, psychological
harm, maldevelopment, / deprivation (WHO).
Interpersonal violence:
 Family members
 Intimate partners
 Friends, acquaintances & strangers
 Child maltreatment
 Youth violence (including that associated with gangs)
 Violence against women (for example, intimate partner
violence & sexual violence) & elderly abuse.
Violence against women, against children, & elder abuse are
particularly prone to underreporting. Reasons:
 Misclassification of death
 Missing stat- victim perpetrator relationship
 No routine investigation / post-mortem
 Victim less likely comes forward for help
Intimate Partner Violence Against Women
 20% to 60% of women have told no one about the violence
 Of women who were injured due to violence, 48%
reported needing health care for the injury, but only 36%
actually sought it.
 30% of ever-partnered women (about one in three)
worldwide have experienced physical and/or sexual
violence by an intimate partner at some point in their lives.
Child Maltreatment
 A quarter of adults (22.6%) worldwide suffered physical
abuse as a child.
 36.3% experienced emotional abuse & 16.3% experienced
physical neglect, with no significant differences between
boys & girls.
 Lifetime prevalence rate of childhood sexual abuse
indicates more marked differences by sex – 18% for girls &
7.6% for boys.
Steps in Prevention & Control
 Surveillance – using data to understand the extent &
nature of it
 Risk Factor Identification – research the cause
 Intervention development – develop strategy & measure
its effect
 Implementation – carry out programmes.
3 levels of public health prevention:
 Primary - aims to prevent violence before it occurs.
 Secondary - focuses on the more immediate responses to
violence such as improving emergency services.
 Tertiary - focuses on the long-term care following violence
such as rehabilitation & reintegration.
VIOLENCES
Types of violence:
 Self-directed - suicidal behaviour & self-abuse
 Interpersonal:
o Family & intimate partner violence - violence largely between family members &
intimate partners, usually, though not exclusively, taking place in the home
o Community violence – violence between individuals who are unrelated, & who
may / may not know each other, generally taking place outside the home.
 Collective - violence committed by larger groups of individuals / by states (e.g.
organized groups, terrorist acts, mob violence, war)
Magnitude of the problem:
 1.3 million people worldwide die each year as a result of violence in all its forms.
 Accounting for 2.5% of global mortality.
 For people aged 15–44 years, violence is the fourth leading cause of death
worldwide
 Tens of thousands of people around the world are victims of non-fatal violence
every day
 Since 2000, about 6 million people globally have been killed in acts of interpersonal
violence.
 Homicide a more frequent cause of death than all wars combined during this
period.
 Non-fatal interpersonal violence is more common than homicide & has serious &
lifelong health & social consequences.
 In 2012 an estimated 475 000 people worldwide were victims of homicide, for an
overall rate of 6.7 per 100 000 population.
 Males account for 82% of all homicide victims.
 38% of female homicides globally were committed by male partners.
 One in every two homicides is committed with a firearm, one in four with a sharp
instrument such as a knife.
 Blunt trauma & suffocation, for instance, are more common in cases of fatal child
maltreatment.
 42% of women who have been physically and/or sexually abused by a partner have
experienced injuries as a result of that violence.
 Children who suffer physical abuse may manifest a variety of internal & external
injuries.
 Elder abuse can also lead to physical injuries ranging from minor scratches &
bruises to broken bones & head injuries.
Impact of Violence
 Women who have experienced intimate partner violence have a 16% greater
chance of having a low birth weight baby & are more than twice as likely to have
an induced abortion.
 Women who have experienced intimate partner violence are 1.5 times more likely
to acquire HIV & 1.6 times more likely to have syphilis.
 Associated with high risk behaviours such as alcohol (10x), drug abuse (6x) &
smoking, which in turn are key risk factors for several leading causes of death,
including cardiovascular disease, stroke (5.8x), cancer (2.4x), chronic lung disease,
liver disease & other non-communicable diseases.
 Higher risk of depression, anxiety, post-traumatic stress disorder & suicidal
behaviour (49x).
 Health & social consequences:
 -Direct cost- the provision of treatment, mental health services, emergency care &
criminal justice responses.
 -Indirect cost- unemployment, absenteeism, health problems that affect job
performance, lost productivity because of premature death; long-term disability;
the provision of places of safety for children & women; disruptions to daily life
because of fears for personal safety; & disincentives to investment & tourism.
6
 VIOLENCES cont…
WHO 2009 had published ‘Violence Prevention: The
Nine WHO’s 2002 recommendations for preventing violence Evidence’. It suggested
1. Create, implement & monitor a national action plan for violence prevention. 1. Preventing violence by developing safe, stable & nurturing
2. Enhance capacity for collecting data on violence. relationships between children & their parents &
3. Define priorities for, & support research on, the causes, consequences, costs & caregivers
prevention of violence. 2. Preventing violence by developing life skills in children &
4. Promote primary prevention responses. adolescents

5. Strengthen responses for victims of violence. 3. Preventing violence by reducing the availability & harmful
6. Integrate violence prevention into social & educational policies, & thereby promote use of alcohol, guns, knives & pesticides: reducing access
gender & social equality. to lethal means

7. Increase collaboration & exchange of information on violence prevention. 4. Promoting gender equality to prevent violence against
8. Promote & monitor adherence to international treaties, laws & other mechanisms to women

protect human rights. 5. Changing cultural & social norms that support violence

9. Seek practical, internationally agreed responses to the global drug trade & the global 6. Reducing violence through victim identification, care &
arms trade. support programmes

1- Safe, stable & nurturing relationships between children & their parents & 2- Developing life skills in children & adolescents:
caregivers:  Help children & adolescents effectively deal with the
 Potential to prevent the life-long negative consequences of child maltreatment. challenges of everyday life.
 Reduce convictions & violent acts in adolescence & early adult- hood  prevent aggression,
 Probably help decrease intimate partner violence & self-directed violence in later life.  reduce involvement in violence,
 Eg : Nurse Family Partnership home visiting programme & Positive parenting  improve social skills,
programme in USA  boost educational achievement & possibly improve job
prospects
3.1- Reducing the availability & harmful use 3.2- Controlling access to lethal
of alcohol means (guns, knives & pesticides): WHO outlined 5 types of programmes:
 Regulating alcohol availability  bans,  Preschool enrichment programmes,
 Increasing alcohol prices  licensing schemes,  Social development programmes,
 Reducing alcohol use in problem drinkers  minimum age for buyers,  Academic enrichment programmes
 Community interventions to improve  background checks  Incentives for youths to complete education
drinking environments  safe storage requirements  Vocational training

Examples of social norms that support violence:
a) Child maltreatment
• Female children are valued less in society than males (e.g.
Peru, where female children are considered to have less
social & economic potential).
• Children have a low status in society & within the family
(e.g. Guatemala).
• Physical punishment is an acceptable / normal part of
rearing a child (e.g. Turkey, Ethiopia).
• Communities adhere to harmful traditional cultural
practices such as genital mutilation (e.g. Nigeria, Sudan) /
child marriage.
b) Youth violence
• Reporting youth violence / bullying is unacceptable (e.g.
the United Kingdom).
• Violence is an acceptable way of resolving conflict (e.g. the
United States of America).
c) Intimate partner violence
• A man has a right to assert power over a woman & is
socially superior (e.g. India, Nigeria, Ghana).
• A man has a right to “correct” / discipline female
behaviour (e.g. India, Nigeria, China).
• A woman’s freedom should be restricted (e.g. Pakistan).
• Physical violence is an acceptable way to resolve conflicts
within a relationship (e.g. South Africa, China ).
d) Sexual violence
• Sex is a man’s right in marriage (e.g. Pakistan).
• Girls are responsible for controlling a man’s sexual urges
(e.g. South Africa).
• Sexual violence is an acceptable way of putting women in
their place / punishing them (e.g. South Africa).
• Sexual activity (including rape) is a marker of masculinity
(e.g. South Africa).
e) Community violence
• Cultural intolerance, intense dislike & stereotyping of
“different” groups within society (e.g. nationalities,
ethnicities, homosexuals) can contribute to violent /
aggressive behaviour towards them (e.g. xenophobic /
racist violence & homophobic violence).
4- Promoting gender equality 5- Changing cultural & social norms that
 The relationship between support violence
gender & violence is complex.  Social norms approach - seeks to correct
 gender inequalities increase these misperceptions by giving people a
the risk of violence by men more realistic sense of actual behavioural
against women & inhibit the norms,
ability of those affected to seek  Mass media interventions - convey
protection. messages about healthy behaviour to
 Programmes must engage broad populations via television, radio,
males & females. the Internet, newspapers, magazines &
 School initiatives other printed materials
 Community interventions  Laws & policies - make violent behaviour
 Media interventions an offence send a message to society that
it is not acceptable.
6- Victim identification, care & support programmes
 Protecting health & breaking cycles of violence
 A range of interventions can help identify victims & initiate a response
 Screening tools, Mandatory reporting systems, Violence education programmes
 Helplines & psychosocial interventions
 Criminal justice system measures to support victims of violence
The Role of MOH
 Establishing a domestic violence, rape & sodomy database.
 Carry out sensitization training for all health personnel related to violence
prevention & management in order to increase recognition, reporting & to
enhance the quality of management of survivors of violence.
 Strengthening the role of the SCAN team & One Stop Crisis Center.
 Inter-sectoral collaboration.
Issue & Challenges
 As a whole the health sector has inadequate human & financial resources.
 Injury & violence is not consider as priority area in health sector as yet. (NSPNCD
2010-2015; not one of the risk factors)
 Multiple agencies involves to coordinate & coordinating funding is not enough.
 Lack of expertise & interest in Public Health arena.
 Lack of current / extensive research to support policies direction.

7
 CANCER
1. Epidemiology of Cancer 2. Updates on Risk Fc
• A major cause of morbidity & mortality, • Cigarette Smoking & Tobacco Use
• Approximately 14 million new cases in 2012 • Infections
• 8 million cancer-related deaths in 2012 • Radiation
• Most Common Cancer: Global, 2012 • Immunosuppressive Medicines
 Men: Lung (16.7%), Prostate (15%), Colorectum (10%), Stomach (8.5%), Liver (7.5%) • Diet eg low fiber diet
 Women: Breast (25.2%), Colorectal (9.2%), Lung (8.7%), Cervix (7.9%), Stomach (4.8%) • Alcohol
• Most Common Cancer: Malaysia,2007 • Physical Activity
 Both sexes: Breast (18.1%), Colorectal (12.3), Trakea,Bronchus,Lung (10.2%),Nasopharynx • Obesity
(5.2%), Cervic Uteri ( 4.6%),Lymphoma ( 4.3%), Leukimia (4.1%), • Environmental Risk Factors
Ovary(3.6%),Stomach(3.5%),Liver(3.3%) • Industrialisation of food e.g GMO but difficult
 Male: Trakea, Bronchus ,Lung (16.3%), Colorectal (14.6%), Nasopharynx (8.4%), Prostate to find causality
(6.2%), Liver (5.5%), Lymphoma ( 5.5%), Leukimia (5.2%), Stomach (4.3%), Bladder (3.2%), • Additive to prolong the food ( need further Ix
Brain, Nervous System (3.2%) such as HACCP & Food Quality Control
 Female: Breast (32.1%), Colorectal (10.0%), Cervic Uteri (8.4%), Ovary(6.5%), Trakea,  Genetic (5-10%)
Bronchus,Lung (5.4%), Corpus Uteri (4.1%), Leukimia (3.2%), Lymphoma ( 3.2%), Thyroid  Occupational
(3.0%), Stomach(2.8%)
3. Community misconception
5. MOH policy & strategic plan  NSP-NCD • Cancer is not cure
• Cancer cause patient suffered & death

4. Early detection & screening

Issues:
• Ineffective referral system
• Incompetency of medical officer in detecting Ca
eg. vague symptom, index of suspicious
• Cancer is under reporting
• Loss of f/up before confirmation of diagnosis
• Late notification to Ca registry

7. Cancer & molecular research

updates

8. Related NGOs in Malaysia for

Cancer
• National Society of Cancer
Malaysia (NSCM)
• Majlis Kanser Nasional
(MAKNA
• Malaysian Anti-Cancer
Associations(MACA)
• Pink Ribbon Deeds (PRIDE)
• Breast Cancer Welfare
Association (BCWA)
• Hospis Malaysia

8
 6. WHO strategic plan CANCER cont…

Risk factor Target Policy Options

• Responsible ≈70% of • Oral cancer screening

• A 30% relative
lung CA burden in high risk
reduction in
• Tobacco free initiave group…linked with
• Tobacco prevalence of current
• MBAR timely treatment
tobacco use In person
• JBAR • Tobacco user
aged 15+ years
• IKBAR • Betel-nut chewer

• Physical activity
• Dietary control
• Weight control
**WHO Global Action Plan for the Prevention
& Control of Noncommunicable Disease 2013-
• A 10% relative
reduction in
• Population-based
• Physical activity prevalence of
colorectal cancer
5x/week for 30 insufficient physical
screening, including
minutes activity.
through fecal occult
• High fiber diet  • A 30% relative
blood test, as
colorectal CA reduction in mean
appropriate, at age
• ↓ red & preserved population intake of
>50, linked with
meat  colorectal CA salt/sodium.
timely treatment
• Halt the rise in
diabetes & obesity
• Prevention of liver
cancer through
Hepatitis B
immunization
2020

• Vaccination against
human papilloma
• Hep B/C 
virus, as appropriate
Hepatocellular CA
if cost-effective &
Cancer Prevention

• HPV  Cervical CA
affordable, according
• Liver fluke 
to national program
(WHO)

CholangioCA of bile
• Infections & policies
duct
• Helicobacter pylori 
Gastric CA • Population based
• Schistosomiasis  cervical cancer
Bladder CA screening

• Environmental 
Arsenic • Prevention of cervical
• Food  Aflatoxin / cancer through
• Pollution Dioxin screening
• Air pollution • Visual inspection
• Cigarette smoke with acetic acid
• Coal fires VIA
• Pap smear /
Cervical cytology
• Radon gas from soil &
building material
• UV light  skin
• Radiation
• Basal cell CA
• Squamous cell CA
• Melanoma

• Occupational
• Asbestos  Lung CA
carcinogen
• At least 10% relative
reduction in the
• Cirrhotic liver disease harmful use of
• Alcohol
 Liver CA alcohol, as
appropriate, within
the national context • Population-based
breast cancer &
mammography
• Others
screening (50-70 yrs)
linked with timely
treatment

9
 CANCER cont
9. Palliative care for cancer patients
WHO DEFINITION OF PALLIATIVE CARE: Palliative care is an approach
that improves the quality of life of patients & their families facing the
problem associated with life-threatening illness, through the prevention
& relief of suffering by means of early identification, impeccable
assessment & treatment of pain & other problems, physical, psychosocial
& spiritual.
Need holistic approach
Palliative care:
• provides relief from pain & other distressing symptoms;
• affirms life & regards dying as a normal process;
• intends neither to hasten / postpone death;
• integrates the psychological & spiritual aspects of patient care;
• offers a support system to help patients live as actively as possible until
death;
• offers a support system to help the family cope during the patients illness
& in their own bereavement;
• uses a team approach to address the needs of patients & their families,
including bereavement counseling, if indicated;
• will enhance quality of life, & may also positively influence the course of
illness;
• is applicable early in the course of illness, in conjunction with other
therapies that are intended to prolong life, such as chemotherapy /
radiation therapy, & includes those investigations needed to better
understand & manage distressing clinical complications.

Type of cancer Strategic plan & policy

Breast • 3 main activities for breast cancer screening in Malaysia:
 Breast Self Awareness (BSA) / Breast Self Examination (BSE)
 Clinical Breast Examination (CBE)
 Mammography screening.
• MOH promoting BSE & annual breast examination by trained health workers as part of breast cancer awareness campaign since 1995.
• MOH implement 3 steps: Look for any breast changes, Feel for any lumps & Response by reporting any changes at the nearest clinic as BSA activities.
• Current screening policy :
 encouraging breast self examination in all women as breast awareness promotion program & focuses on clinical breast examination
 for all women above the age of 20 - 39 years, they are encouraged to undergo clinical breast examination by trained health care providers every three years
 those above the age of 40 years & those with high risks of getting breast cancer regardless of the age should have annual clinical breast examination (KKM,
2002)
• Indication of mammography
 women with a history of breast atypia on previous breast biopsy, history of cancer in one breast &/ / ovarian cancer & also women with a family history of
breast cancer in one / more of first / second degree relatives (mother & sisters) before the age of 50 years.
 For those under the age of forty at the discretion of the doctor & if the patient wishes to do so (MOH, 2006).
 Mammogram is done free of charge in government facilities for those who are ‘eligible’ (‘high risk’).
 Mammography screenings are also available in the private centers for any women including those who are not high risks & may cost between RM 100 to RM
120.
Cervical • Primary prevention: HPV vaccination starting 2010
 Given at age 13 y/o, 3 doses
 Dose: 0,1,6 month after first dose
• Secondary prevention: Pap smear screening
 For those sexually active, aged 20-65 y/o
 If the first two consecutive Pap results are negative, screening every three years is recommended.
Colorectal Definition risk group:
• High Risk
 Personal history of either polyps / colorectal cancer
 Family history of either polyps / colorectal cancer
 Personal history of inflammatory bowel disease
 Family history of cancer such as breast, uterine & ovarian.
• Average Risk
 Asymptomatic individual aged over 40 years
• Low Risk
 Asymptomatic individuals aged less than 40 years & other than those listed above.

High-Risk Asymptomatic Individuals

 Annual DRE & faecal occult blood testing begin at age 35
 Age 40: Total colonoscopy (index colonoscopy)/contrast barium enema & sigmoidoscopy.
• These examinations can be carried out earlier in patients with a strong family history (two / more relatives with colon cancer / relatives who have had cancer at
ages younger than 40).
• Subsequent colonoscopy / barium enema should be repeated every 3-5 years with yearly faecal occult blood tests.
• Patients with uretero-colonic anastomosis should be followed yearly, with flexible sigmoidoscopy as a minimum & colonoscopy if the area of anastomosis cannot
be visualised by sigmoidoscopy.

Screening:
1) Faecal Occult Blood Tests
 Concept: colonic neoplasms such as early-stage cancer & large adenomatous polyps will bleed à become detectable by occult blood test
 FOBT with the Hemoccult II test with appropriate diagnostic follow up of a positive test. Annual screening leads to a greater reduction in mortality than
biennial screening.
 Limitations:
 false positive tests with many patients undergoing the risk & discomfort of a full bowel examination when they do not have cancer.
 False negative test as failure to detect many polyps & some cancers
2) Sigmoidoscopy (Summary of recommendations)
 Mass screening at a national level cannot be recommended for the average risk individuals.
 Full history & physical examination to identify the patients risk group
 CEA levels are not recommended in the asymptomatic individuals as a screening method.
 Faecal occult blood testing for screening for colorectal cancer, unless as part of a mass program, is not recommended.
 For the high-risk individual, surveillance should be carried out at regular intervals. In these individuals, colonoscopy is recommended. Where not available,
barium enema can be performed as an alternative.
 A detailed cancer registry of all patients with colorectal cancer in Malaysia need to be set up
Liver Hep B Vaccination since 1989: compulsary for newborn & adult in high risk group

10
 SUBSTANCE ABUSE
Substance abuse refers to the harmful / hazardous use of
psychoactive substances, including alcohol & illicit drugs. Substance abuse
refers to:
• drugs use
Psychoactive substance use can lead to dependence syndrome – a cluster
• alcohol use
of behavioral, cognitive, & physiological phenomena that develop after
• tobacco use
repeated substance use & that typically include a strong desire to take the
drug, difficulties in controlling its use, persisting in its use despite harmful
consequences, a higher priority given to drug use than to other activities &
obligations, increased tolerance, & sometimes a physical withdrawal
state.
Criteria for alcohol dependence (3 / more within 12 month period): Risk factors
1. Family member with an
addiction / alcohol
dependence
2. Age: start using alcohol at
younger age
3. The people you associate
with friends/peers ,
especially for young people
surrounded by
alcohol/alcohol easily
available
4. Stress. many people turn
to alcohol as a way of
unwinding  more frequent
use  increased tolerance
5. Mental disorders
Criteria for substance abuse (DSM IV)
One / more of the following, occurring within
a 12-month period:
• Recurrent substance use -> failure to fulfill
major role obligations at work, school, /
home
• Recurrent substance use in situations
which it is physically hazardous (e.g.
driving an automobile)
• Recurrent substance-related legal
problems (e.g. arrests for substance-
related disorderly conduct)
• Continued substance use despite
persistent / recurrent social /
interpersonal problems caused /
exacerbated by the effects of the
substance (e.g. arguments with spouse
about consequences of intoxication,
physical fights)
WHO & WHERE TO SCREEN?
• Clinic – medical patients; A&E - accident
victims, intoxicated patients; psychiatric
hosp – psychiatric pt; court, jail, prison –
violent criminals; military services –
enlisted men&officers; work place –
workers with productivity problems &
absenteeism
• Tertiary prevention
 to reduce existing impairments &
disabilities & to minimize suffering
caused by alcohol abuse.
 form of treatment that involves the
prevention of worsening conditions &
the emergence of secondary problems.

Harmful effects: Treatment for

Alcohol Dependence
-NCDs- CVDs, cirrhosis of the
liver & various cancers.
-CDs- HIV/AIDS, tuberculosis &
STIs
 alcohol consumption weakens Alcohol withdrawal Non-pharmacological Pharmacological
the immune system
-unintentional & intentional
injuries (RTA, violence, &
suicides)
Motivational
Rehydration Naltrexone Acamprosate
interviewing

Programs in Malaysia/global
• Alcohol & Substance Abuse Prevention &
Reduction Unit: responsible for activities Thiamine
relating to prevention & reduction of supplements espc. Cognitive behavioral Acamprosate +
Disulfiram
‘Wernicke–Korsakoff’s interventions Naltrexone
psychoactive drug use, abuse & dependence syndrome’
including alcohol.
• “Global Strategy to Reduce Harmful Use of
Alcohol” was endorsed by 63rd World Health
Benzodiazepine :
Assembly in May 2010 enhance GABA
Relapse prevention
Other medications
• Vision : is to improve health & social strategies
activity in CNS
outcomes for individual, families &
communities, with considerably reduced
morbidity & mortality due to harmful use of
alcohol & their social consequences. Residential
rehabilitation
• NGO: Alcoholics Anonymous Malaysia programs
• screening, brief intervention & referral to
treatment (SBIRT)
• pilot project: 4 health clinics in Tuaran &
Keningau, Sabah

11
 SUBSTANCE ABUSE cont…
Drug abuse
• include: cannabis, cocaine, heroin & other opioids, & ecstasy.
• globally, in 2010 between 153 million & 300 million people aged 15-
64 used an illicit substance at least once
• 15.5 million-38.6 million (problem drug users)
• “problem drugs” based on “the extent to which use of a certain drug
leads to treatment demand, emergency room visits (often due to
overdose), drug-related morbidity (including HIV/AIDS, hepatitis etc.),
mortality & other drug-related social ills”
Cannabis/marijuana
• most commonly used illicit drug in the US, among young people.
• the use, possession, sale, cultivation, & transportation of cannabis in
the US under federal law is illegal but the federal government has
announced that if a state wants to pass a law to decriminalize
cannabis for recreational / medical use they can do so.
Amphetamine type stimulant
• mephedrone:similar to ecstasy.
• once available as a "legal" alternative to drugs such as ecstasy
• white powder that is snorted, swallowed
• effect: can make you feel awake, confident, happy, causes vomiting &
headaches, insomnia, agitated & hallucinatory states
Opiates (heroin / opium)
• opiate drugs: heroin, opium, morphine, pethidine, codeine,
oxycodone, methadone, buprenorphine.
• opiates  used intravenously, smoked (opium) / snorted (white
heroin).
• heroin: addictive drug, risk of overdose.
• opiates have been used both recreationally (outlawed) & medicinally
(widespread)
Cocaine
• available in powder & injection.
• effect: makes user energetic, happy, wide awake & over-confidence
(can lead to taking risks)
• possible to die of an overdose from overstimulating the heart &
nervous system, which can lead to a heart attack.
Health consequences:
• infectious dx (for injecting drug users)-HIV, Hep B&C
• administration of drug other than injection  unprotected sex 
↑risk of HIV
• treatment demand- 20% of problem drug users received tx for their
drug dependence
• drug-related deaths: unintentional overdose, suicide, HIV& AIDS,
trauma
• female underpresented in tx: limited services for tx & care of female
drug users; stigma a/w being female drug user  accessibility to tx
more difficult
Malaysia
• 2009 : 7,123 new abusers
• 2010 : 17,238 new abusers
• 2010: 23,642 abusers 2010, ↑ 50.24% compared to 2009.
• there were 6,404 (27.1%) relapsed abusers detected
• In 2010,
1. Penang 3,753 (15.9%) abusers
2. Selangor 3,548 (15.0%)
3. Kedah 2,507 (10.6%)
4. Terengganu 2,377 (10.1%)
5. Kelantan 2,360 (10.0%).
• main type of drugs abused:
• amphetamine-type stimulants (36.2%), heroin (27.4%),
morphine (21.9%), ganja/cannabis (12.7%)
• male abusers 97.5%, female abusers 2.5%
• drug abusers: age group of 19 – 39 years old (72.4%), adults
(≥40 years) 18.3%, teenagers (13 – 18 years old) 9.3%
Treatment
• long term substitution: methadone (opiate addiction)
• substitution, to alleviate withdrawal sx: methadone
• blocking response: naltrexone (to block opiate effects)
• modification of craving: naltrexone (blocks opiate receptors-
also of value in treating other addictions)
Risk factors
• Family-lack of mutual attachment & nurturing by parents /
caregivers, ineffective parenting, chaotic home environment,
lack of a significant relationship with a caring adult, caregiver
who abuses substances, suffers from mental illness, / engages
in criminal behavior.
• Outside the family-Inappropriate classroom behavior, such as
aggression & impulsivity, academic failure, poor social coping
skills, association with peers with prob in school, peer, &
community environments.
• Others-The type of drug used  Smoked / injected  produce
a quick, powerful effect  reach the brain faster  fades
faster  increased tolerance
C&C 1 Malaysia Clinic
• open access services
• admission voluntary
• addicts are patient
12
 SUBSTANCE ABUSE cont…
PREVENTION&CONTROL
1. National Anti-Drugs Agency (NADA)
• set up in 1996 to monitor & control the drug situation in Malaysia
• responsible for the formulation of policies relating with the drug abuse
preventive education & treatment & rehabilitation of drug dependants
• 4 core strategies in eradicating the supply of & demand for drugs in the
country are: prevention; treatment & rehab; law enforcement;
international cooperation
• NADA has outline a few strategies:
 to implement prevention programs by targeting high risk male
teenage/adolescence.
 to ensure the implementation of prevention program in higher
education institutions, family institutions, workplace & high risk
community
 to empower civil society as a preventive agent
 to maximize the usage of new media in Preventive Education &
Publicity
 to enhance the number & involvement of voluntary
 to increase the cooperation between strategic partners & smart
partnership in implementing the prevention program
2. The Cabinet Committee on the Eradication of Drugs
• established in 2004
• has 3 sub-committees:
i. Prevention Education & Publicity – chaired by the Minister of
Education
ii. Law Enforcement – chaired by the Minister in charge of Legislative
Affairs.
iii. Treatment & Rehabilitation – chaired by the Health Minister
• this system is replicated at the state level & reaches into the district level.
Drug Treatment & Rehabilitation
• Objective: to enable drug dependents to overcome the physical &
psychological addiction to drugs & to thereafter live a drug-free
lifestyle.
• NADA implements 4 methods of treatment & rehabilitation:
Rehabilitation in the Institution (Cure & Care Rehabilitation Centre),
Rehabilitation in the Community (Cure & Care Service Centre, Caring
Community House), Open-Access Services (Cure & Care 1Malaysia
Clinic), Rehabilitation through career (Cure & Care Vocational Centre)
1) Triage centre
• holds drug abusers mandated for compulsory treatment for 2 weeks
• they are screened, evaluated & categorized according to the severity
of their drug use
2) C&C Rehab Centre (CCRC) (PUSPEN)
• For severe drug dependents
• One PUSPEN  drug treatment centre for drug abusers free from
criminal records & those possessing high motivations to recover from
drug use.
3) C&C Service centre (CCSC)
• -56 Cure & Care Service Centres till now
• Role & functions are:
 To plan & implement drug preventive programs at the district
level;
 To provide facilities for drug treatment & rehabilitation for
volunteering drug addicts;
 To provide counselling & advisory services to those who require
such services;
 To manage & determine the rehabilitation program that would
best suit the clients. These clients are referred to the centre by the
police / themselves volunteering for treatment & rehabilitation;
 To provide follow-up services to those addicts who are mandated
under the Supervision Program & for those who have completed
their program at the Government Treatment & Rehabilitation
3. MeSVIPP Unit
• The Alcohol & Substance Abuse Prevention Sub-unit -> responsible for
activities -> prevention&reduction of psychoactive substances abuse
including alcohol use, misuse & dependence
• Objectives:
i. to formulate policy & plan of action to prevent & control drug &
alcohol related harm
ii. To develop the programme for preventing & reducing alcohol & drug
abuse related harm
iii. To monitor & evaluate the implementation of the substance
prevention programme
iv. Surveillance on disorder & diseases related to drug & alcohol abuse
v. To plan & initiate research related to illicit drug use & alcohol
consumption
vi. To collaborate with other relevant agencies in preventing & controlling
drug & alcohol abuse.
4. Law
• Malaysia’s drug laws are found in six (6) major statutes. They are:
i. The Dangerous Drugs Act 1952
ii. The Poisons Act 1952
iii. The Drug Dependants (Treatment & Rehabilitation) Act 1983
iv. The Dangerous Drugs (Special Preventive Measures) Act 1985
v. The Dangerous Drugs (Forfeiture of Property) Act 1988
vi. The National Anti-Drugs Agency Act 2004
5. Multi agency
• Enforcement of drug laws: The Narcotics Crime & Investigations
Department (NCID) of the Royal Malaysia Police (RMP)  main; the Royal
Malaysian (Narcotics Division).
• Pharmaceutical Services Division (MOH) enforces the Poisons 2 Act 1952
 controls the sale, import & export of poisons, precursors & essential
chemicals
Centres.
4) C&C Community Home (CCCH)
• objectives: to mobilize the local community to address the drug
problem at their communities.
• target group: anyone who has drug problem
• services provided are: integration in society, help support group,
community service, reference information
5) C&C 1Malaysia Clinic
• approach from institutionalized rehabilitation to an open approach
(Open Access Services)
Prevention Program
• Activities:
 Drug Free Family
 Drug Free Education (SHIELD, Tomorrow’s Leader)
 Drug Free Workplaces
 Drug Free Community (NSTP, Rakan Anti Dadah, MAWADAH, SMART,
National Anti Drugs Day, MAHABAH)
• Public awareness
• Anti-drug Volunteers
• Activities by NGO:
 PEMADAM involved with prevention
 PENGASIH assisting HIV/AIDS infected addicts
 PENDAMAI & Malaysian Care assisting addicts
• Community based organisations like the Neighbourhood Committees,
Village Development & Security Committees, Women's Organisations,
Youth organisations also participate in drug prevention activities.
• private sector involvement: support drug prevention programmes at
workplace, encouraged in the production of posters, leaflets &
billboards promoting the anti-drug message
• media involvement: through the participation of the Ministry of
Information providing coverage for national & international conferences
& events, launch of campaigns, television & radio talk shows
13
TOBACCO ABUSE
• >5 million world deaths  direct tobacco use,
• >600 000  non-smokers exposed to second-
hand smoke.
• 80% of one billion smokers->low- & middle-
income countries (burden of tobacco-related
illness & death is also heaviest)
• In some countries, children from poor
households employed in tobacco farming (family
income)
• Vulnerable to "green tobacco sickness" 
nicotine absorbed through the skin from the
handling of wet tobacco leaves.
SUBSTANCE ABUSE cont…
Risk factors: Smoking in Women • ETS = main stream + side stream
• Girls & young women of a smoker mother (4x smoke
higher) • Main stream smoke: smoke that
• Peer tobacco / close friends who smoke (4-13x is drawn through the cigarette
higher) into a smoker’s mouth & then
• Exposed to tobacco advertising & promotion exhaled into the environment.
(double) • side stream smoke: smoke that is
• Knowledge, attitudes & beliefs : Pro-smoking released from burning end of a
attitudes/ positive image of smoking & a cigarette
perception that smoking is the norm (4x higher)
• Concern with weight reduction

Treatment for
Factors that promote Smoking
smoking cessation Cessation
• deglamorise&
denormalise tobacco Non-
Pharmacological
use pharmacological
Treatment
Others
• create smoke-free areas Treatment
• tobacco tax increases
• strictly regulate tobacco Nicotine Non-nicotine
products & the tobacco Behavioral Counseling Support Group Replacement Containing Cold Turkey
Therapy Medication
industry
• provision of accessible
smoking cessation Nicotine patch :
Telephone /
Stage of Change Individual NicoDerm CQ, Bupropion Acupuncture
services Quitline
Habitrol
• intensive promotion of
cessation services
Internet-based Varenicline :
Family members Gum : Nicorette Hypnosis
programs Champix

FCTC Lozenge : Commit

Nortriptyline :
/ Nicorette mini Laser therapy
• forced in February 2005. Pamelor
lozenge
• tackle complex factors with cross-border effect include:
 Adopt tax & price measures to reduce consumption
 Ban tobacco advertising, promotion & sponsorship; Nasal spray : Clonidine :
iPhone apps???
 Create smoke-free work & public spaces; Nicotrol NS Catapres
 Put prominent health warnings on tobacco packages;
 Combat illicit trade in tobacco products.
Preventive & strategies programmes
• National Tobacco Programmes :
MPOWER
1993
M  monitor tobacco use & prevention policies
• Framework Convention on Tobacco
P  protect people from tobacco smoke
control (FCTC): 2005
O  offer help to quit tobacco use
• MPOWER: 2008
W  warn about the dangers of tobacco
E  enforce bans on tobacco advertising, promotion & sponsorship
R  raise taxes on tobacco

Problems in Tobacco Control

• Lobby from Tobacco industries.
 discourage government to increase tax
 high tax will lead to smuggling
 proposed annualised & moderate tax regime
 “High sporadic tax increase create a disruptive &
unpredictable business environment to legitimate
manufacturers”
• Incidence of smuggling can affect revenue & cost of
manufacturing  the upward trend was from 14.4% in 2004 to
37.1% in 2010
• Yearly price hike- none in Budget 2012
• Extremely cheap cigarettes being dumped in Malaysia
• Lack of enforcement & prosecution on health standards in terms
of tar content (<20mg) & nicotine content (<1.5 mg) & smoke
free areas
• Low public (smokers’) awareness on real risk of smoking despite
numerous campaigns
• High number of paramedics & doctors who smoke
 It was reported in 1991 from a Malaysian hospital that 18% of
the doctors were smokers, 13% ex-smokers & 69% had never
smoked. All the smokers were male & all except one smoked
only cigarettes (Yaacob & Abdullah, 1993)
14
 ATTENTION DEFICIT HYPERACTIVE DISORDER
Impact of ADHD
• a “persistent pattern of inattention
Epidemiology • Individual – significantly affect
and/or hyperactivity-impulsivity that
• the mean worldwide prevalence of childhood & adult life,
is more frequently displayed & more
ADHD is between 5.29% & 7.1% in  Poor social relationships
severe than is typically observed in
children & adolescents (<18 years)  Tend to have a lower
individuals at a comparable level of
• 3% - 5% of school-aged children occupational status
development”(DSM-IV)
• boys:girls, 3:1 (Mental Health America).  More likely to commit motoring
• most common neurodevelopmental
However, girls may be under diagnosed offences & develop substance
disorder in childhood
• In Malaysia. : Screening for hyperactivity abuse
• s/sx typically appear before the age
& inattention in a survey amongst • Parents & siblings also suffer as a
of 7
children & adolescents between the ages result of the behavioural problems
• can be difficult to distinguish
of 5 – 15 years  prevalence of 3.9 % associated with ADHD
between ADHD & normal “kid
(MOH,2008)  increased levels of stress are
behavior”
common as are depression &
marital discord

Symptoms
DSM-IV Diagnostic Criteria ADHD Diagnostic Criteria
 Inattention Symptoms (at least 6 symptoms required)  Sx present b4 age 7
 Fails to give close attention to details or makes careless mistakes in schoolwork,  Clinically significant impairment in
work, etc. social/academic/occupation
 Difficulty sustaining attention  sx that cause impairment present in
 Does not seem to listen when spoken to directly ≥2 settings (e.g., school/work,
 Does not follow through on instructions & fails to finish schoolwork, chores, etc. home, recreational settings)
 Difficulty organizing tasks & activities  Not due to another disorder (e.g.,
 Avoids tasks requiring sustained mental effort Autism, Mood Disorder, Anxiety
 Loses things necessary for tasks or activities Disorder)
 Easily distracted by extraneous stimuli
 Forgetful in daily activities

 Hyperactivity-Impulsivity Symptoms (at least 6 symptoms required)

 Difficulty playing or engaging in activities quietly
 Always "on the go" or acts as if "driven by a motor”
 Talks excessively
 Blurts out answers
 Difficulty waiting in lines or awaiting turn
 Interrupts or intrudes on others
 Runs about or climbs inappropriately
 Fidgets with hands or feet or squirms in seat
 Leaves seat in classroom or in other situations in which remaining seated is
expected

3 major subtypes Risk factors

• Attention-Deficit/Hyperactivity, Predominantly • Familial:
Hyperactive-Impulsive Type 1. Blood relatives (such as a parent or sibling) with ADHD or another
• if ≥6 sx of hyperactivity-impulsivity (but ≤6 sx of mental health disorder
inattention) persisted for at least 6 months.
• Attention-Deficit/Hyperactivity Disorder, • Child:
Predominantly Inattentive Type 1. Exposure to environmental toxins — such as lead, found mainly in
• if ≥6 sx of inattention (but ≤6 sx of hyperactivity- paint & pipes in older buildings
impulsivity) persisted for at least 6 months. 2. Premature birth
• Attention-Deficit/Hyperactivity Disorder, Combined 3. Low birth weight
Type 4. Brain Injury
• if ≥6 sx of inattention & ≥6 sx of hyperactivity- 5. Watching television at a young age (below 3 years)
impulsivity have persisted for at least 6 months.
• Maternal:
1. Maternal drug use, alcohol use or smoking during pregnancy
DIET 2. Maternal exposure to environmental poisons — such as
• For decades, speculation & folklore have suggested polychlorinated biphenyls (PCBs) & lead — during pregnancy
that foods containing preservatives or food coloring 3. Maternal stress
or foods high in simple sugars may exacerbate ADHD.
• Many controlled studies have examined this question.
• To date, no adequate data set has confirmed the
speculation.
15
 BIPOLAR (MANIC DEPRESSIVE) DISORDER
Epidemiology
• the lifetime prevalence of BD I was 0.6% & BD II
0.4% (according to World Mental Health Survey
in 11 countries)
• The prevalence varied between countries
 USA had a lifetime prevalence of 1.0% &
1.1% for BD I & BD II respectively  the
highest
 Japan, the lifetime prevalence was 0.1% for
both BD I & BD II
• The mean age of onset for illness is:
 BD I 18.2 years
 BD II 20.3 years
 Women: BD I 1.1%; BD II 1.3%
 Men : BD I 0.8%; BD II 0.9%
• previously called manic depression.
• a form of major affective disorder/mood
disorder
• defined by manic/hypomanic episodes
(changes from one's normal mood
accompanied by high energy states).
Risk Factors
 ↑ the risk of developing BD
 having a first-degree relative, eg
parent/sibling/twin with bipolar disorder
(Kieseppa et al, 2004)
 Periods of high stress
 Drug/alcohol abuse
 Major life changes, such as the death of a
loved one / other traumatic experiences
 Comorbid
 Anxiety disorder
 PTSD
 ADHD
 Addiction / substance abuse
 Physical health problem (e.g. heart disease,
thyroid disorder)
Specific type of disorder:
• Bipolar I disorder
 had at least 1 manic episode
 manic episode may be followed by hypomanic/major depressive
episodes
 mania sx cause significant impairment in your life & may require
hospitalization
• Bipolar II disorder
 had at least 1 major depressive episode lasting ≥2/52 & ≥ 1 hypomanic
episode lasting ≥ 4/7, but no manic episode
• Cyclothymic disorder
 had ≥ 2 years of periods of hypomania sx (less severe than hypomania
episode) & periods of depressive sx (less severe than major depressive
episode) [1 year pccurs on children&teenagers]
• Other types
 for example, bipolar & related disorder d/t medical condition, such as
Cushing's disease, multiple sclerosis / stroke
 another type is called substance & medication-induced bipolar &
related disorder.
Prevention
there is no way to prevent its onset, but there are some things you can do.
 Pharmacotherapy-treating mood sx in high-risk cohorts
 psychosocial intervention to prevent or delay the onset of BD
 family-focused therapy (FFT) OR FFT for high-risk children (FFT-HR)
 regular medical check-up
 don’t become isolated
 healthy lifestyles - healthy diet, get the right amount of sleep, exercise
regularly, avoid alcohol & illegal drugs
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Epidemiology
• globally, estimated 121 million suffer from
depression
• major depression is a prevalent disorder in
the general population, with rates ranging
from 2.3% to 4.9%
• lifetime prevalence in US & Western Europe:
13.3–17.1%
• depression is the most important risk factor
for suicide with about 21% of the patients
with recurrent depressive disorders
attempting suicide
• cause high economic burden for society
• significant suffering, high morbidity &
mortality, & psychosocial functional
impairment are typically associated with
depressive disorders.
• in primary care settings:
• under recognition & under treatment of
depressive disorders are common
• depressive disorders should be considered
with patients with multiple medical problems
(DM,HPT, cancer), ageing, unexplained
physical symptoms, chronic pain or use of
medical services that is more frequent than
expected
Risk Factors
1) Genetics
2) Death or loss
3) Conflict with family or friends
4) Abuse-physical, sexual, emotional
5) Major events –losing jobs, divorced
6) Serious illness – menopause, cancer
7) Certain medications - varenicline
8) Other personal problems – social isolation
9) Substance abuse -eg:amphetamine
• Short-Term Effects of Amphetamine
• Coming down from amphetamines, the
user feels immense exhaustion, severe
fatigue & depression. These after-
effects of amphetamine lasts up to 2
days & usually spur another search for
the drug high.
• Long-term Effects of Amphetamine
• After several cycles of use & coming
down, the body begins to show the
long-term effects of amphetamine.
• The long-term effects -arrhythmia,
ulcers, breathing difficulties, skin
problems, malnutrition from not eating,
exhaustion & seizures. Long-term use
also leads to mental disorders &
psychosis.
• Withdrawal
• Withdrawals are the symptoms
experienced as the amphetamines leave
the body permanently. This causes a
variety of different symptoms as the
body tries to live without the drugs.
• Withdrawals from amphetamines
include insomnia, mood swings, cravings
for the drug, confusion, difficulty
concentrating, irritability & depression.
DEPRESSIVE DISORDER
ICD-10
typical sx of depressive episodes
• depressed mood
• loss of interest & enjoyment
• reduced energy
common sx of depressive episodes
• reduced concentration & attention
• reduced self-esteem & self-confidence
• ideas of guilt & unworthiness
• bleak & pessimistic views of future
• ideas or acts of self-harm or suicide
• disturbed sleep
• diminished appetite
a) Mild Depressive Episode
• At least 2 typical symptoms + 2 common symptoms
• No symptom should be present to an intense degree
• Minimum duration of whole episode is at least 2 weeks
• The person has some difficulty in continuing ordinary work & activities.
b) Moderate depressive episode
• At least 2 typical symptoms + 3 common symptoms
• Some symptoms may be present to a marked degree
• Minimum duration of whole episode is at least 2 weeks
• The person has considerable difficulty in continuing social, work or domestic activities
c) Severe depressive episode without psychotic symptoms
• All 3 typical symptoms + at least 4 common symptoms
• Some of the symptoms are of severe intensity
• Minimum duration of whole episode is at least 2 weeks ( may be <2 weeks if symptoms are
very severe & of very rapid onset.
• The person is very unlikely to continue with social, work or domestic activities.
d) Severe depressive episode with psychotic symptoms
• A severe depressive episode
• Delusions, hallucinations or depressive stupor are present.
e) Recurrent depressive disorder
• Repeated depressive episodes (mild, moderate, severe)
• No history of independent manic episodes
Prevention and Treatment of MDD
Sleep & depression
• Eating healthy diet
• Depression cause sleep problems & sleep
• Regular exercise
problems may contribute to depressive
• Taking time out for fun and relaxation
disorders.
• Screening for depression - DASS
• Sx of depression may occur before the
onset of sleep problems or sleep
Treatment of MDD
problems may appear before sx of
Mild depressive episode
depression.
• non-pharmacological: problem-solving,
• Insomnia is very common among
counselling, and supportive therapy,
depressed pt. People with insomnia have
exercise
a 10 times risk of developing depression
• follow-up appointment (within 2 weeks) so
• There is a risk of misdiagnosis. For eg,
patient’s condition can be monitored
depressed mood can be a sign of insomnia
closely
• Children & adolescents with depression
• consider antidepressant medication: if
suffer from sleep problems such as
depression persists or worsens; if pt had a
insomnia or hypersomnia (excessive
past history of moderate to severe
sleepiness) or both.
depression
• Certain people are more likely than others
to develop depression, including women
Moderate-severe depressive episode
& older adults.
• Offer antidepressants
• Older adults: higher rates of depression &
• Drug of first choice is an SSRI (Fluoxetine,
sleep problems may be d/t physical
Fluvoxamine, Sertraline)
illness.
• Women: motherhood &hormonal
Depression with psychotic features
changes (menstruation, menopause) may
(hallucination and delusion)
contribute  depression.
• antipsychotic + antidepressant
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Schizophrenia is a term used to describe a major
psychiatric disorder that alters an individual’s
perception, thought, affect & behaviour
Risk Factors
1. Those with family history of schizophrenia,
with history of obstetric complications
(preeclampsia, extreme prematurity, hypoxia
or ischemia during birth)
2. Cannabis abusers
3. Individual living in higher level of urbanisation
(1.40-fold increased risk)
4. Offspring of older fathers
5. Unmarried mother
6. Those with h/o childhood CNS infection
Criteria for Schizophrenia
A. Characteristic symptoms: ≥ 2 of the following,
for one-month period (or less if successfully
treated):
1) delusions
2) hallucinations
3) disorganized speech
4) grossly disorganized or catatonic behavior
5) negative symptoms i.e., affective
flattening, alogia, or avolition
B. Social/occupational dysfunction
C. Duration: Continuous signs of the disturbance
persist for at least 6 months.
D. Schizoaffective & Mood Disorder exclusion
E. Substance/general medical condition exclusion
F. Relationship to a Pervasive Developmental
Disorder
Management of schizophrenia
includes:
• Pharmacotherapy: AP (antipsychotic)
• Electroconvulsive Therapy (ECT)
• appropriate psychosocial & service level
interventions (PSR)
People with schizophrenia who present at
primary care should be provided with:
1. Assessment & early treatment
2. Early referral to specialist care
3. Initial treatment & urgent referral in the
acutely-ill patient
4. Collaboration with hospital-based psychiatric
services
5. Registration of patients at health clinics & the
National Mental Health Registry
Universal Prevention
• Raising the awareness, promoting referrals
from PC physicians
• PUFA, especially omega-3 in fish oil, & vitamin
D warning signs recognition, crisis management
Selective Prevention (targeted prevention)
• Prenatal infection/malnutrition,
perinatal/obstetric complications, older
paternal age, winter season of birth,
separation from primary caretakers during the
first year of life, absence of protective family
environments, childhood physical & sexual
abuse, urbanicity, cannabis use,
unemployment, never-married marital status,
& history of migration
Indicated Prevention
• PACE: CBT + risperidone;
• PRIME: Olanzapine;
• RAP: Antipsychotics vs. antidepressants;
• OPUS: Standard vs. integrated treatments;
• EDIE: Cognitive therapy;
• GRNS: Amisulpiride;
• VGH: Omega-3
SCHIZOPRENIA
Epidemiology
• prevalence of schizophrenia: approaches 1%
internationally.
• median incidence rate: 15.2 per 100,000 (range
of 7.7 to 43.0 per 100,000)
• the incidence was noted higher: males, urban,
migrant population
Malaysia
a. Gender & age
• > 60% males
• peak age of presentation: 30 years old
b. Ethnic group
• 54% Malays
• 28% Chinese
• 9% Indians
• 9% others
c. Marital status & occupation
• 80% single, divorced, widowed or separated
• 70% unemployed
d. Body weight
• 60% had normal BMI (<25)
Consequences of schizophrenia
1. Mortality
• people with schizophrenia:showed suicide &
other accidents as leading causes of death in
both developing & developed countries
(Jablensky et al., 1992)
2. Social disability
• in self care (dressing, personal hygiene),
occupational performance (studying),
functioning in relation to family & household
members (interactions with spouses, parents,
children or other relatives), functioning in a
broader social context (social interaction with
community members, & participation in
leisure & other social activities)
3. Social stigma
4. Impact on caregivers (economy, emotional
reactions, coping problems with social
withdrawal)
5. Social costs
• loss in DALYs estimated in 1990 at slightly
below 13 million, which represents about 1%
of the global burden of the disease deriving
from all causes
• by the year 2020, with more than 17 millions
of DALYs lost, accounting for 1.25% of the
overall burden (Murray & Lopez, 1996)
Prevention & control
• Promotion—create environments & conditions
that support behavioral health & the ability of
individuals to withstand challenges & reinforce
the entire continuum of behavioral health
services.
• Prevention—Delivered prior to the onset of a
disorder, intended to prevent or reduce the risk
of developing a behavioral health problem, such
as underage alcohol use, prescription drug
misuse & abuse, & illicit drug use.
• Treatment—Identification of an individuals with
mental disorders & the standard treatment for
those disorders
• Recovery— reduce relapse,recurrence, help with
abstinence & to provide rehabilitation, improve
QOL
e. Duration of Untreated Psychosis (DUP)
• the time period from onset of the first
psychiatric symptom to initiation of
antipsychotic treatment
• mean DUP 28.7 months
• males had a shorter DUP (23 to 26 months)
than female (30 to 33 months)
f. Family history & co-morbid conditions
• 21.6% had family history of mental illness
• 20% had some form of co-morbidity
• substance abuse:commonest (80%)-cannabis,
amphetamine
g. Medical co-occurring conditions
• > 40%->co-occurring medical condition
(DM,HPT)
h. Care setting at first contact
• > ½ treated as outpatients
• 1/2 of the patients had their first contact as
inpatients
SERVICE LEVEL INTERVENTION
Consist of:
• Community Mental Health Team (CMHT)-
multidisciplinary team of mental health staff
&provide assessment, treatment & care to a
defined population
• Assertive Community Treatment (ACT)-multi-
disciplinary care with involvement of
psychiatrist care provided for people with
serious mental illness
• Day Hospital Care-improve clinical symptoms,
reduce admission rates & enhance
engagement
• Vocational Rehabilitation
• Crisis Intervention
• Home Treatment Team
• Case Management
TYPES OF PSYCHOSOCIAL INTERVENTIONS
• Family Intervention-communication skills &
problem solving, coping with stress, early
• Psychoeducation-aspects of illness, treatment
& side effects of medications
• Social Skills Training - practicing specific skills:
self care, conversation skills, conflict handling,
making friends, assertiveness
• Cognitive Remediation Therapy (CRT) -
teaching new information processing
strategies, individualizing treatment, helping
to transfer the improvement in cognitive
function to real life setting
• Cognitive Behavior Therapy (CBT): focus : cope
with persistent delusions & hallucinations
• Counseling & Supportive Psychotherapy
• Multimodal Intervention:
• Treatment Adherence
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 NCD (MODIFIABLE) RISK FACTORS & PREVENTIONS
GLOBAL (WHO Global Action Plan For NCD Prevention 2013-2020)
RISK FACTOR
INTERVENTION
TARGET
MODIFIABLE Environment Community Individual Clinical
I Want sihat , Kem Kesihatan
Sihat Sepanjang Hayat
Built walking & cycling Rakan Muda
Encourage Effective
path to encourage KOSPEN
exercise at least 30
physical activity e.g Physiotherapist
Physical Reduce 10% min per exercise 5
Putrajaya –healthy School placement in
activities prevalence of times per week
setting Satu murid satu sukan primary health
(physical physical Promote
Program 10,000 langkah clinic.
inactivity) inactivity extracurricular
,path Workplace
physical activity
Recreational park Jom naik tangga
Smoke free area Aerobic session
Conduct obesity clinic
School
Provide healthy school meals
(kantin sihat)
Ban hawkers selling outside
3 meals portion
school area
30% Food Diary for Nutritionist
Increase taxation on fast Ban vending machine
Nutrition reduction “diabetes patient” placement at KK,
food , increase taxation School-based NCD risk factor
Unhealthy diet sodium intake booklet conduct obesity
on fat, sugar, salt, reduce screening & intervention
in mean Healthy recipes for clinic
subsidy on sugar
population diabetes
Workplace
Menu sihat for meeting meal
Signage at the Community
center
Smoke free city-melaka /
campus ,increase
taxation
Kampung bebas asap
MPOWER
rokok(KEBA) Melaka
Monitoring tobacco used
Criteria-free smoke
& prevention policy
30% restaurant, no cigarettes, no
Protect people from
reduction smoking area Kempen tak nak Quit smoking
tobacco smoke
Smoking prevalence in Blue ribbon campaign – merokok clinic
Offer help to quit
current Hussin nasi kandar
smoking
tobacco use World tobacco day
Warn danger
New Breath Beginning
Enforce ban on tobacco
Ramadhan Campaign
Raise tax on tobacco
advertising, promotion &
sponsor
Screening, brief intervention
& referral to treatment
(SBIRT) eg Sabah & Sarawak
Drinking & driving
10% punished if level >80mg/dl
Increase tax Behaviour
reduction Syariah lawforbidden to Screen
Alcohol abuse Laws & legislation intervention therapy
harmful use muslim
Ban alcohol
of alcohol NGO : Alcohol anonymous
Malaysia –ex alcohol abuser
share experience (peers
group support group)

Kempen minda sihat

Labour act  working (Anxiety, depression,
hours Psycho rehabilitation centre stress)
Stress PSY treatment
SOCSO DASS
Islamic approach

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