4th Symposium on the Burden of Neglected Diseases

The 4th Symposium on the Burden of Neglected Diseases was held on the 17th January 2009 at the UMMC Clinical Auditorium. The symposium was attended by more than 60 participants. The theme for the symposium was ‘Redefining the Economic Burden of Dengue and Chikungunya in Malaysia’. The symposia addressed the burden of neglected diseases with the view of encouraging the development and implementation of cost-effective solutions.

Given the vast scope of this subject, each symposium will have a theme that clearly focuses on a disease (or diseases carried by the same vector) affecting a specific region or population. National and international experts will be invited to present key findings from their research and field data; papers presented will cover different
aspects of estimation of disease burden including morbidity, mortality, and socio-economic burden such as immediate and longterm costs. Cost effectiveness of different solutions such as vaccines, traditional and innovative vector control strategies will also fall within the scope of this symposia series.

The first three symposia took place in Ahmedabad (India), Brasilia (Brazil) and Madurai (India) respectively. The fourth symposium in this series, to be held at the University of Malaya, Kuala Lumpur, will focus on refining the estimated burden of Aedes mosquito-borne diseases such as dengue and chikungunya affecting Malaysia and neighbouring countries. It is our hope that such focused symposia hosted around the world will, between
them, help address the current or recent global burden of neglected diseases. Proceedings (peer-reviewed abstracts) will be made available on the Internet by the conveners to develop the ‘body of knowledge’ on this subject.

Papers were presented by speakers from both local and overseas, including Dr. Ng Chiu Wan and Dr. Mas Ayu Said. The symposium had also for the first time incorporate a teleconference session from the United States. Congratulations for Dr Ng Chiu Wan and team for successfully organising the symposium.

Papers Presented

Immediate cost of dengue and chikungunya to Malaysia: An estimate


Authors: Lee Han Lim1, S.S. Vasan2,3, Tiina M. Murtola2,3, Robert W. Field2, Dileep V. Mavalankar4, Hong-Fei Gong3, Nazni Wasi Ahmad1, Lokman S. Hakim1, Shahnaz Murad1, Ng Chiu Wan5, Lucy Lum Chai See6, Jose A. Suaya7, Donald S. Shepard7

1WHO Collaborating Centre for Ecology, Taxonomy and Control of Vectors of Malaria, Filariasis and Dengue, Institute for Medical Research, Ministry of Health Malaysia, 2Department of Engineering Science, University of Oxford, 3Oxitec Limited, 4Indian Institute of Management, Public Systems Group, 5Department of Social and Preventive Medicine, University of Malaya, Faculty of Medicine, 6Department of Paediatrics, Faculty of Medicine, University of Malaya, 7Schneider Institutes for Health Policy, Heller School, Brandeis University,

Background: Dengue is a growing problem and chikungunya is an emerging threat in Southeast Asia.
Methodology and Principal Findings: Using Monte-Carlo analysis, we have estimated the immediate cost of dengue to Malaysia to be in the range of US$ 88-215 million (mean US$ 133 million) per annum. Fortunately, chikungunya is not yet a major problem and its estimated immediate cost is only an additional US$ 1.2 million. However, it is an emerging threat and could cost Malaysia an additional US$ 134 million if its epidemic activity reaches the recent levels of dengue. While the impact on tourism is traditionally not included in the cost of illness studies; it could reach an additional US$ 171 million if there were a major outbreak of dengue or chikungunya in Malaysia.
Conclusions and significance: Effective control measures could generate substantial offsets to illness costs. While not analysed in this study, the emotional and long-term burden of illness and deaths due to these viral infections are additional adverse impacts.

Costs of Dengue: An Eight-Country Prospective Study

Authors: Jose A. Suaya1, Donald S. Shepard1, João B. Siqueira2, Celina T. Martelli2, Lucy C. S. Lum3, Lian
Huat Tan3, Sukhontha Kongsin4, Sukhum Jiamton4, Fàtima Garrido5, Romeo Montoya6, Blas Armien7, Rekol Huy8, Leticia Castillo9, Mariana Caram1, Binod K. Sah1, Rana Sughayyar1, Karen R. Tyo1, Scott B. Halstead10

1Schneider Institutes for Health Policy, Heller School, Brandeis University, U.S.A., 2Federal University of Goiás, Goiana, Brazil, 3University of Malaya Medical Center, Kuala Lumpur, Thailand, 4Mahidol University, Bangkok, Thailand, 5Ministry of Health and Social Development, Caracas, Venezuela, 6Ministry of Health and Social Assistance, San Salvador, El Salvador, 7Instituto Conmemorativo Gorgas de Estudios de la Salud, Panama City, Panama, 8The National Dengue Control Program at the National Center for Malaria, Phnom Penh,
Cambodia, 9National Health Laboratory, Guatemala City, Guatemala, 10Pediatric Dengue Vaccine Initiative (PDVI), International Vaccine Institute, Seoul, Korea

Background: Despite the growing worldwide burden of dengue fever, the globaleconomic impact of dengue illness is poorly documented. Using a common protocol, we present the first multicountry estimates of the direct and indirect costs of dengue cases in eight American and Asian countries.
Methods: We conducted prospective studies of the cost of dengue in five countries in the Americas (Brazil, El Salvador, Guatemala, Panama, and Venezuela) and three countries in Asia (Cambodia, Malaysia, and Thailand). All studies followed the same core protocol with interviews and medical record reviews. The study populations were patients treated in ambulatory and hospital settings with a clinical diagnosis of dengue. Most studies were performed in 2005. Costs are in 2005 international dollars (I$).
Results: We studied 1,695 patients (48% pediatric and 52% adult); none died. The average illness lasted 11.9 days for ambulatory patients and 11.0 days for hospitalized patients. Among hospitalized patients, students lost 5.6 days of school, while those working lost 9.9 work days per average dengue episode. Overall mean costs were I$514 and I$1,394 for an ambulatory and hospitalized case, respectively. With an annual average of 574,000 cases reported, the aggregate annual economic cost of dengue for the eight study countries is at least I$587 million. Preliminary adjustment for under-reporting could raise this total to $1.8 billion, and incorporating costs of dengue surveillance and vector control would raise the amount further. Conclusion: Dengue imposes substantial costs on both the health sector and the overall economy.

Burden of Disease of Dengue in the Philippines


Authors: Maridel P. Borja1,2, Fely Marilyn E. Lorenzo2,3

1Department of Epidemiology and Biostatistics, University of the Philippines Manila, The Philippines, 2Institute of Health Policy and Development Studies, University of the Philippines Manila, The Philippines 3Department of Health Policy and Administration, University of the Philippines Manila, Philippines

The Philippines is a high threat area for dengue with an incidence of 19.8/100,000) and a case fatality of 1% to 4%. Demonstration of the high burden of dengue might convince local government units to consider it a priority health problem. This study was conducted in six cities to determine the burden of dengue in terms of its economic impact and disability-adjusted life years (DALYs) lost.

The methods of data collection were rapid survey, review of medical records and documents, delphi survey of experts, key informant interviews and focus group discussions. The rapid survey included 570 households with 2,924 members. Estimation of DALYs adopted the Global Burden of Disease methodology. Sensitivity analyses resulted in good triangulation despite using different data sources, adjustments and assumptions. Approximately 18,074 (21.96/100,000) DALYs are lost per year due to dengue indicating that its health impact in the Philippines is more akin to the Southeast Asian Region (23.92/100,000) than to the Western Pacific Region B (8.39/100,000).
Because DALYs are sensitive to variations in case fatality, case management should lower the risk of dying especially among the young.

Dengue DALYs in the Philippines is close to the Western Pacific DALYs of measles, Japanese encephalitis, hepatitis B, malaria and schistosomiasis and is greater than that of leprosy. Therefore, dengue must be accorded as much importance as these diseases in terms of prevention, control and research initiatives.

The dengue morbidity cost per patient which is the sum of the cost of diagnosis (Php 2,531), cost of treatment (Php 1,223) and estimated income loss of patients and watchers (Php 357) is Php 4,123 (US$ 85.36). The national morbidity cost is Php 447.6 million. Serological confirmation reduces this to Php 301.4 million, a cost variance large enough to

Seroprevalence of chikungunya infection in Pantai Remis, Perak, Malaysia


Authors: Mas Ayu Said1, Jamal I-Ching Sam2, Ahmad Hatim Sulaiman3, Noran Naqiah M Hairi1, Chan Yoke Fun2, Lai Li Rong2

1Dept. of Social and Preventive Medicine, 2Dept. of Medical Microbiology, 3Dept. of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

Objectives: To determine the seroprevalence, clinical manifestations, and quality of life due to Chikungunya infection one year after an outbreak in Bagan Panchor fishing village, Pantai Remis, Perak, in 2006.
Method: A cross-sectional study was conducted with face-to-face interviews from house to house. All residents in Bagan Panchor, including Malaysians and foreign workers, were eligible for the study. Participants were interviewed for clinical manifestations of the disease, its duration and the severity of the disease. They were also asked about quality of life in terms of activities of daily living (ADL), depressive symptoms and economic loss due
to infection. Serum samples from interviewed subjects were tested for anti-Chikungunya antibodies by neutralization assay. A probable case was defined as presence of any symptoms of Chikungunya during the outbreak, and a case was defined as being positive for anti-Chikungunya antibodies by neutralization. A contact was defined as an asymptomatic subject living in Bagan Panchor during the outbreak. The Ministry of Health
outbreak report was used as a baseline to compare with some of the findings in this study.
Results: A total of 191 subjects participated, including 44 probable cases and 31 contacts previously identified by the MOH. 31 new probable cases and 81 new contacts were identified in this study. 71 (37.1%) subjects claimed to have had symptoms for Chikungunya during the outbreak, including fever (30.6%), arthralgia (26.3%), rash (22.3%), muscle pain (12.8%), headache (10.6%) and arthritis (10.6%). The duration of symptoms ranged from 1-100 days. In terms of ADL, 2 people had significant restriction of activities, and one person required a wheelchair. 7 people were independent in ADL but with limited activities due to muscle pain and arthralgia. The duration of disabilities ranged from 2-60 days. Only 3 people had depressive symptoms. 9 people had absences from work ranging from 2-90 days. 5 students were absent from school, ranging from 3-7 days. Of 81 subjects who consented to blood taking, 49.4% were seronegative and 50.6% were seropositive for Chikungunya.
Conclusion: Chikungunya infection was an infectious disease with high morbidity and significant socioeconomic impact due to absences from work and school.

Quality of life of dengue patients: A recent study involving government hospitals in Malaysia


Lucy C.S. Lum1, Jose A. Suaya2, Lian H. Tan1, Binod K. Sah2, Donald S. Shepard2

1Faculty of Medicine, University Malaya, Malaysia, 2Schneider Institutes for Health Policy, Heller School, Brandeis University, Waltham, Massachusetts, USA.

Background: Although the disease burden of dengue is increasing, the impact on the quality of life (QoL) remains unknown.
Methods: A prospective study to determine the QoL of confirmed dengue patients using the EUROQoL visual thermometer scale was carried out at the University Malaya Medical Centre.
Results: Of the 207 participants, 40% were ambulatory and 60% hospitalized. Of eight health domains, 6.2 and 5.0 domains were affected in the hospitalized and ambulatory cohorts, respectively (p<0.001), with cognition and interpersonal activities affected most. All patients experienced a drastic decrease in their QoL from the onset of symptoms. QoL deteriorated to the lowest point (40% of healthy status) between the third and seventh days of illness. The duration of impaired QoL (9 days for ambulatory or 13 days for hospitalized patients) was longer than the duration of fever (5 and 7 days, respectively).
Conclusion: Symptomatic dengue has major effects on patients’ health.

Households insecticides market: Control of Aedes and other mosquitoes in Malaysia


Authors: Lee Nai Pin, Muney Serit, Ridzuan Ismail, Chooi Lam Khong, Lee Teck Peng, Koay Chew Aik

Malaysian CropLife & Public Health Association

The Malaysian CropLife and Public Health Association (MCPA) is the national organization which represents the plant science and public health industries of Malaysia. It is affiliated to CropLife Asia, one of the six regional nodes of CropLife International. CropLife organizations are found in 91 countries.

The industry is guided by the International Code of Conduct on the Distribution and Use of Pesticides and MCPA seeks to ensure that pesticides are used judiciously, correctly and safely.

New pesticides are developed after undergoing stringent research processes including screening for bio-efficacy, toxicity, environmental fate, carcinogenicity, mutagenicity, teratogenicity and adverse effects on reproduction. While these products are developed mainly for agriculture, a significant amount is used by the non-crop sectors which include the public health.

Household insecticide is a major component of the public health industry in Malaysia. Estimates of market size could not be accurately determined due to several reasons. Sales figures are tightly guarded commercial secrets. Market surveys tend to capture “retail consumer prices” mostly in urban areas. On the other hand market estimates by the industry are generally based on propriety market intelligence, and the basis for the estimation of value falls between COGS (cost of goods sold) and “average sales price”. As such there will always be a significant difference between the market surveys and the market size estimates by the industry. MCPA reported that the household insecticide market for 2007 was RM 204 mio while the market survey (by a market research agency) for the period July 2007 to June 2008 was RM 308 mio. There is a need to educate the public to better understand and use household insecticides more effectively for the control of Aedes in their homes and communities.

Use of national health accounts to track costs of vectorborne diseases in Malaysia


Authors: Ng Chiu Wan1, Rozita Halina Hussein2, Jameela Zainuddin3

1Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, 2Institute for Health Systems Research, Ministry of Health, Malaysia, 3Malaysia National Health Accounts Unit, Planning and Development Division, Ministry of Health, Malaysia

The National Health Accounts (NHA) refer to a methodology used for estimating the totality of national health expenditure flows from sources of spending to various uses of that spending – both public and private – within the health system of a country. Most countries have adopted the basic framework used in the Organisation for Economic Cooperation and Development (OECD) System of Health Accounts. This is also the basis of the Malaysia National Health Accounts (MNHA) which was established, initially as a project funded jointly by the Government of Malaysia and the United Nations Development Programme (UNDP) in 2001 and which was later institutionalised in the Ministry of Health in 2005. The MNHA estimates showed a gradual increase in total health
expenditures from 2.9% of GDP in 1997 to 3.8% in 2002 to 4.3% of GDP in 2006. The total health expenditures for that year was RM24.8 bil.

One of the more recent developments has been the conduct of Cost of Illness (COI) studies using the classifications found in the NHA framework. These studies permit disaggregation of total health expenditures to individual diseases or disease groups by provider categories. Unfortunately, the methodology requires diverse detailed health expenditures and utilisation datasets which at the moment are not available in Malaysia.

Current MNHA estimates only allow for partial disaggregation of the costs for some preventive activities for vector-borne diseases in Malaysia such as maintenance of surveillance systems and fogging activities. In 2006, a total of about RM43 mil was spent on these activities which constitute about 4.7% of total expenditures for public health programmes.

From malaria to dengue and chikungunya: Evolution of priorities, funding and research in medical entomology in Malaysia


Authors: Lee Han Lim, Nazni Wasi Ahmad, Lokman S. Hakim

Medical Entomology Unit, Institute for Medical Research, Kuala Lumpur, Head, Infectious Disease Research Centre, Institute for Medical Research, Kuala Lumpur

The Institute for Medical Research conducted research on malaria immediately after its inception in 1900, focusing mainly on incrimination of malaria vectors and means of controlling them. The research culminated in the implementation of Malaria Eradication Programme (MEP) in 1966 since the successful conduct of a pilot MEP in Negeri Sembilan earlier. Although MEP had successfully reduced malaria cases from >300,000 cases annually, it was converted to Malaria Control Programme in 1982. Despite this, research on malaria vectors continued to receive strong funding support, until the 1990s when malaria cases in the country were greatly reduced, for the first time, to below 10,000 cases. From 1996 to 2008, funding for research on malaria vectors totalled RM 2,913,620 for 37 projects. During this period, two vector-borne diseases, dengue and chikungunya posed a serious public health threat, as effective vaccines and anti-viral treatments are not available; the only option being to control the vectors, Aedes aegypti and Ae albopictus. For the same period, total funding for dengue vectors research totalled RM 2,980,336 for 71 projects; while research on chikungunya vectors was first supported in 2007 and 2008 totalling RM 187,325 for 2 projects; reflecting changing research priority in favour of these 2 viral diseases. Research on malaria vectors centred on vector control technologies such as the use of insecticide-impregnated bednet, indoor residual spraying, insecticide resistance and zoonotic transmission; while in dengue and chikungunya vectors, research priorities centred on effective novel vector control and virological studies.