1. Malaria Situation & Drug Policy Malaysia Infectious Disease Consultant/Physician MOH Malaysia

2. Malaria incidence 1961-2004

3. Incidence and Incidence Rate Malaria in Malaysia 1995-2004 6154

4. MALARIA CASES AND INCIDENCE RATE BY GEOGRAPHICAL AREA (STATE) 2004

6. Malaria Parasite Distribution Malaysia 2004

7. Malaria Age-specific Incidence Rate Malaysia 2004

8. Malaria cases among Malaysian and foreign citizens 2000-2004 2070 16.3% 3232 25.3% 3468 31.5% 1627 25.7% 2009 32.6% 4145

9. Malaria deaths and CFR Malaysia 1995-2004

10. Malaria Deaths contributed by Malaysians and foreign citizens in 2004 Mortality Rate: Malaysian: 18/4145 (0.43%) Foreigners: 17/2008 (0.84%)

11. MANAGEMENT: DRUG THERAPY: PROPHYLAXIS: 1. FANSIDAR & CHLOROQUINE 2. PROGUANIL & CHLOROQUINE 3. DOXYCYLINE RISK GROUP: 1. VISITORS TO HIGH RISK AREA IN SABAH,SARAWAK & PAHANG 2. ARMY : WORKING OR FIELD TRAINING IN HIGH RISK AREA 3. LOCAL PEOPLE WHO WORK OR ENTER HIGH RISK AREA-surveyors,loggers or jungle related occ.

12. MANAGEMENT DRUG TREATMENT: -TO ALL CONFIRMED CASES -ALL CASES WILL BE HOSPITALISED EXCEPT THOSE FROM REMOTE AREA PLASMODIUMDRUGS (1 st line) Remarks FALCIPARUMCQ & SP +/- PQ 1.QUININE & DOXY For foreigners/immigrants 2. SP & PQ (Single dose) -Orang Asli lives in remote area -mass radical Rx during large outbreak in remote area VIVAXCQ & PQ NON COMPLICATED

13. COMPLICATED CASES 2. SEVERE MALARIA (i) QUININE at 10mg/kg with 5% Dextrose over 4 hours then 8hourly AND DOXYCYLINE (ICU or HDW Management) 1.RESISTANT MALARIA (i) QUININE & DOXYCLINE- physician approval (ii) MEFLOQUINE – requires Health State Director Approval

14. Status of P. falciparum resistance to antimalarial drugs West Malaysia. 28.5% CQ resistance (1963 by Montgomery & Eyles) > 60% by the mid-90's (Hakim et al, 1996) in Peninsular Malaysia. 47.4% SP resistance for the first time in Malaysia. 2000-2001, two 28-day in vivo studies on the CQ+SP combination reported 51.4% (19/37) resistance in Kemaman, Terengganu state, 62.5% (15/24) in Air Bah, Perak state. Sentinel surveillance was started early 2003 in 10 sites looking at treatment response (unpublished Report, 2003. VBDC, MoH)

15. Summary of response by drugs (completed 28 days follow-up) in 2003 DrugValid cases Completed D28 Incon- clusive (%) Adequate response (%) Early failure (%) Late failure (%) Total failure (%) CHL937320 (20.4) 40 (54.8) 18 (24.7) 15 (20.5) 32 (45.2) SP521240 (78.8) 10 (83.3) 1 (8.3) 1 (8.3) 2 (16.7) CHL + SP 16411252 (31.7) 77 (68.8) 16 (14.3) 19 (17.0) 35 (31.3) Total309197112 (36.2) 127 (64.5) 35 (17.8) 35 (17.8) 70 (35.5)

16. Summary of response by drugs in 2004 (completed 28 days follow-up) DrugValid cases Completed D28 Incon- clusive (%) Adequate response (%) Early failure (%) Late failure (%) Total failure (%) CHL + PQ 673730 (44.8%) 8 (21.6%) 9 (24.3%) 20 (54.1%) 29 (78.4%) SP + PQ 4018422 (55.0%) 14 (77.8%) 2 (11.1%) 2 (11.1%) 4 (22.2%) SP + CQ + PQ 372017 (45.9%) 15 (75.0%) 2 (10.0%) 3 (15.0%) 5 (25.0%) Total1447569 (47.9%) 37 (49.3%) 13 (86.7%) 25 (33.3%) 38 (50.7%)

17. East Malaysia. There are no studies documented on chloroquine resistance from 1990. In 1996, the VBDC, MoH reported 29.4% SP treatment failures ( 28-day in vivo study done in Tawau, Sabah, East Malaysia). -100% sensitivity to Mefloquine and Quinine, -16.6% (2/12) failures to Artesunate 20 mg/kg x 6 days (Unpublished report, 2003). 1999-2000 in Sarawak - 43% failures to the CQ+SP combination (Cox-Singh et al, 2003). There are 8 surveillance sites in Sarawak and Sabah (4 each) as part of the MoH/IMR National Surveillance Program that started early this year.

18. Distribution of Insecticide Treated Bednets in Malaysia 1995 & 2000-2004

19. 1.CROSS BORDER MIGRATION - Sarawak & Indonesia - Northern part of Pen Malaysia & Thailand 2.Foreign workers from endemic areas- urban malaria outbreaks & emergence of resistance 3.Geographical inaccessibility : Remote settlement/interior area- 4.As the number of malaria cases comes down - delay in diagnosis/ management 5. Inadequate drug efficacy monitoring & resistance surveillance 6. Lack in number of experienced personnel in malaria management 7. Unavailability of anti-malaria drug policy CHALLENGES

20. ACT issue ACT will be a definite treatment alternative for Malaysia because of its benefits Formulation of anti malaria drug policy.