Pencegahan dan Kawalan Denggimelalui pengurusan persekitaran bandar
secara mampan dan lestari
Veeramohan Supramaniam, FRSH
Malaysian Association of Environmental Health
Pengenalan
• Kejadian dan (Kematian) akibat denggi kian meningkatselepas wabak teruk pada tahun 2010:
• 46,171 (134) @ 2010,
• 19,884 (34) @ 2011,
• 21,900 (35) @ 2012,
• 43,346 (92) @ 2013
• 100,661* (190) @ 13 Dis 2014
* Unit Vektor KKM hingga minggu ke-50 berakhir 13 Dis 2014
Source: http://idengue.remotesensing.gov.my/idengue/index.php
4+ dekad Denggi di Malaysia*
12,077 20,973
143,262
372,224
43,346
100,661
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
1973-
1982
1983-
1992
1993-
2002
2003-
2012
2013 2014
Jumlah kes
173.7%
683.1%
* Geraf dihasilkan oleh MAEH daripada data asas dari KKM
259.8%
Hasil perlaksanaan kaedah alternatifMajlis Daerah Manjung Ref: 2001: 497 cases27.3 percent reduction in 2002 (361 cases) - 3rd quarter intervention. Sitiawan and TLDM Lumut - epidemic free until today. (Trf 01.04.04)
Majlis Daerah Perak Tengah Ref: 2008 : 250 cases52.00 percent drop in 2009 (120 cases); 35.00 percent drop in 2010 (78 cases); 44.87 in 2011 (43 cases); 18.60 in 2012 (35 cases);14.29 in 2013 (30 cases); 4 cases up to 05 April 2014 (Rtd 29.03.14)
Setapak, DBKL Ref: 2006 : 2431 cases 11.35 percent reduction in 2007 (2155 cases);46.36 percent reduction in 2008 (1156 cases); 14.01 percent reduction in 2009 ( 994 cases);16.60 percent increase in 2010 (1159 cases); 65.31 percent reduction in 2011 ( 402 cases);22.14 percent increase in 2012 ( 491 cases);79.02 percent reduction in 2013 ( 103 cases);
0
20000
40000
60000
80000
100000
120000
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
-62.3%
Nationwide Intensive Campaign
Nationwide Intensive Campaign
Bersih & Indah Campaign II
National Cleanliness and Anti-mosquito Campaign
Bersih & Indah Campaign I
Keberkesanan Kempen Kebersihan Nasional
-73.7% -53%
-63%-30%
-18%
Worst epidemic before the new millennium
Nationwide Cleanup CampaignIntensive Cleanup Campaign
-15.9%
-56.9%
10 min Search & DestroyCampaign
100,661 (190) 13/12/14
Garispanduan Kawalan DenggiKementerian Kesihatan Malaysia
• Pemeriksaan premis dari rumah ke rumah
• Penggunaan racun kimia (fogging, ULV, Abate SG-1) dll
• Penguatkuasaan – perintah berhenti kerja, pendakwaan
• Penubuhan dan penglibatan pasukan COMBI
• Gotong royong di kawasan perumahan dankediaman
Malaysia mengkritik WHO keranagagal menangani wabak denggi*
Malaysia criticized the WHO for failing to tackle the spread of
dengue in the region, which saw 242,000 cases of the mosquito-
borne disease in 2009 and 831 deaths so far this year.
Health Minister Liow Tiong Lai, who is chairing a World Health
Organization regional conference this week, said the UN body needed
to push countries to adopt a more comprehensive strategy to deal
with the threat.
"We want them to do a lot more. We want the WHO to do more on
dengue, we think they are not doing enough," he told reporters on the
sidelines of the meeting of the organization's Asia Pacific member
states.
* Romen Bose, Agence France-Presse – Wednesday 10/13/2010, 16:47:00
Garispanduan Kawalan Denggi WHO*
* WHO Comprehensive Guidelines for Prevention and Control of Dengue and Dengue Haemorrhagic Fever - Revised and expanded edition, 2011 - Chapter 7 (Page 60)
Pusingan hidup nyamuk Aedes
Beberapa saat –
bertahun-tahun
Telur kering
2 – 3 hari
3 – 4 hari (kalau
makanan wujud)
2 – 3 hari
X
Tiada Makanan
Telur nyamuk diletak pada dindinglembab/kering, BUKAN ATAS AIR
Penetasan telur S. albopicta yang matang
Stegomyia aegypti• Nyamuk rimau (Egyptian Tiger)
• Nyamuk vektor berasal dari Egypt
• Membiak dalam rumah dan halaman
• Menggigit di bawah paras pinggang
• Tidak efisyen meminda jangkitan melalui telur(menjangkiti 5 generasi)
• Tahan kekeringan dan menetas dalam 3 hariapabila ditenggelami air.
Stegomyia albopicta• Nyamuk rimau (Asian Tiger)
• Nyamuk vektor tempatan
• Membiak di celah tumbuh-tumbuhan
• Mengejar dan menggigit
• Sangat efisyen meminda jangkitan melaluitelur (semua generasi terjangkit)
• Tahan kekeringan dan menetas serta mertaapabila ditenggelami air hujan panas.
Hasil Kajian Vektor di Malaysia
TOT - S. albopicta berbanding S. aegypti
Kenapa Denggi harus dicegah?
• Kejadian kes = Produktiviti Negara terjejas
• Kematian kes = Kehilangan Modal Insan
• Beban Ekonomi = +/- 20 % GDP
• Kesan kepada Pelancongan
Beban Ekonomi kepada negara
Kos kawalan denggi di Malaysia (2013)
Kos rawatan & kawalan untuk 12 bulan RM196,000,000
Kos setiap kes yang dilapurkan RM5,441.27
Kos setiap rawatan pesakit luar RM680.78
Kos harian rawatan kes di wad RM163.54
Kos pengurusan setiap penduduk negara RM7.14 /warga
Shepard2, et al. (2013) - Use of Multiple Data Sources to Estimate the
Economic Cost of Dengue Illness in Malaysia
Beban ekonomi akibat denggi di Malaysia (Oxitech)
Kos setiap 10,000 kes = US$13 juta* RM 44,460,000*
Kos untuk 100,661* (190) kes denggi
(setakat 13/12/14)
RM 436,277,088
Kehilangan hari kerja / 10,000 kes 940,000 hari
Kos rawatan wad / kes / hari = US$718 RM 2,283.24
Kehilangan pengeluaran ekonomi / kes 56 hari
Oxitech - http://www.oxitec.com/health/dengue-information-centre/the-economic-burden/
* Bersamaan 20% the Pengeluaran Kasar dalam negara.
* Berdasarkan pertukaran matawang = RM 3.42 / USD
Dry spell, diseases spoil Visit Malaysia Year by G Vinod *Dengue cases rise dramatically, TB makes a comeback and the haze makes an early appearance.
PETALING JAYA: It’s been a bad start for Visit Malaysia Year 2014, but neither the Tourism Ministry nor the tourism industry is to blame.Rather, the culprits are disease and bad weather.
According to the Health Ministry, more than 20,000 cases of dengue were recorded between the beginning of the year and the end of last week. This was a huge jump from the 4,760 cases recorded in the same period last year. Forty-five of this year’s dengue victims have died.
To make matters worse, a disease thought to be long gone—tuberculosis (TB)–has made a comeback to the Malaysian health hazard list.The Health Ministry said 1,520 people lost their lives to TB in 2012 alone. They were among 22,710 people infected with the disease.No one is sure how TB has resurfaced in the country, but some quarters blame illegal immigrants, pointing out that they entered the country without health screening.
The weather is also discouraging tourists from coming to the country. Malaysia has been facing an unseasonal dry spell since early February. Water levels at several dams in Selangor, Negeri Sembilan and Johor are reaching critical points. The Meteorological Department says the rains will start coming at the end of March or in early April. Meanwhile the National Water Services Commission (SPAN) is rationing water distribution in Negeri Sembilan, Johor and Selangor.Selangor is the most industrialised state in Malaysia, and the water rationing has affected many businesses, especially restaurants and agriculture based enterprises. Rice and palm oil production are also affected.
If the dry spell goes on for another month, oil palm yields will keep dropping for six months to two years down line, according to people in the industry. This concern pushed up palm oil prices by 8% in February.
With the dry spell creating bush fires in Sumatra, coupled with illegal burning by farmers there, the notorious “haze season” has made an unwelcome return to Malaysia. Air Pollutant Index (API) readings on Friday breached the hazardous level at Port Klang (358) and Banting(311), prompting authorities to order a temporary closure of 202 schools. Readings have also shown a deterioration in air quality in Petaling Jaya, where the API is 185, and in Shah Alam, where it is 164.
Cloud seeding has induced some rain, but not enough to clear the haze or even improve dam levels. No one knows for sure when theweather will improve. In the meantime, health facilities will be busy treating increasing numbers of people complaining of respiratory problems and other maladies brought on by heat and polluted air.
*Free Malaysia Today - March 15, 2014
Bagaimana Denggi berlaku?
• Manusia/mawas pembawa virus
• Nyamuk Aedes peminda virus.
• Persekitaran / kediaman = tempat membiak
Mana satu mampu kita kawal?
Punca Virus – Pembiakan Nyamuk – Manusia
Siapa mangsa denggi - 2013
Jangkitan berlaku di luar*
* Dengue Bulletin – Volume 25, 2001.
Jangkitan di kawasan lapangan
Denggi di kalangan murid sekolah
Statistik Pembiakan Vektor* Malaysia 1992 - 2001
0
1000000
2000000
3000000
4000000
5000000
6000000
Houses Insp 4306403 4822081 4724210 4555906 4397754 4239489 5071478 3915499 3956344 4249307
Houses +ve 46440 48649 33378 43773 41612 42902 36203 27961 21117 26856
Aedes Index 1.1 1 0.7 1 0.9 1 0.7 0.7 0.5 0.6
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
*Source: Vector HQ MOH
Status Pembiakan Nyamuk di kawasan lapangan Bandaran
• 99 peratus nyamuk membiak di persekitaran
• 1 peratus masuk ke premis yang didiami orang
Bagaimana virus berjangkit?
• Ae. albopictus membiak liar di kawasan tanahlapangan/tanah terbiar dalam semak samun
• Ae. albopictus lebih berpeluang menemuipembawa virus denggi 2 hari sebelum “onset”
• Ae. albopictus yang terjangkit memindahkanjangkitan kepada penduduk tempatan yang lalu lalang berhampiran tanah lapangan yang menjadi “epicentre” jangkitan.
Cara nyamuk vektor terjangkit*
*Frontiers in Immunology Journal, 17 June 2014.
Pergerakan manusia pembawa virus
Source: Control of Vector-Borne Diseases Unit, Ministry of Health, Malaysia
Cases radiating from epicentres
Status Orang Asing di Malaysia 2014
Negara berbeban tertinggi 2013
Ketibaan pelancong 2012
Ministry of Tourism
Kawasan kediaman pekerja asing di Lembah Kelang
Langkah terbaik kawalan nyamuk
• Pastikan “epicenter” jangkitan
• Bersihkan kawasan sekitar dari semak samun
• Jadikan kawasan lapangan tidak sesuai untukpembiakan nyamuk
• Jangan guna semburan racun kecuali ada kes
• Galakkan tumbuhan berbunga yang memikatnyamuk dan pemangsanya.
• Gunakan racun jejentik jenis EC bukan SG
Pemetaan Pergerakan Tempatan
Epicentre – Laluan pejalan kaki
Epicentre – Laluan tepi Taman
Masa yang sesuai untuk semburan
Source: Bebas Denggi - Unit Kawalan Penyakit Bawaan Vektor JKWP KL dan Putrajaya
“Urban Heat Island Effect”
“Temperature Inversion”
Masa terbaik – “thermal fogging”
Asap tidak lesap dengan cepat
Tanah terbiar di Taman Rakyat Kg. Koh, Manjung (projek perintis)
Reproduced with permission from A Pictorial Report (MPM) - Operations Anti-Aedes
Tanah selepas dibersihkan
Reproduced with permission from A Pictorial Report (MPM) - Operations Anti-Aedes
Tanah terbiar di Taman Maju, Seri Iskandar
Tanah dibersihkan dan dilakukanlandscaping di Seri Iskandar
Sebelum tanah terbiar dibersihkan, Setapak
Selepas pembersihan tanah terbiar, Setapak
Akta Kerajaan Tempatan 1976
Pekerja menyembur racun serangga di Yoyogi Park, Jepun, yang dipercayai punca wabak denggi pada 28 Ogos, 2014.
Semburan kabus ULV
Kawalan VektorSemulajadi
Nyamuk terperangkap di sawanglabah-labah
Peranan utama nyamuk
Bukti nyamuk menghisap madu
Nyamuk adalah pemindahdebunga
Pemangsa nyamuk paling berkesan
Mentadak
Kekatak
Cecicak
Telur diletak pada kelopak bunga
Sesemut – pemangsa telur nyamuk
Mamalia terbang
Burung
Penghijauan and Biodiversifikasi bandar
Cuba : Contoh Pertanian di Bandar
Pertanian Organik di Havana, Cuba
MAEH VP signs MOU* with DBKL
* Partners and Stakeholders in LA21 since 16 Dec 2013
Kesan nyata dan positif
• Pengurusan kawasan lapangan merupakankaedah yang terbaik untuk mencegahjangkitan virus bawaan nyamuk secara terusdan transovarial oleh Stegomyia sepertiDenggi, Chikungunya serta Zika fever di kawasan bercorak bandar.
• Penurunan kes dapat dilihat dalam 2 atau 3 minggu selepas diputuskan jangkitantempatan (Batu and Lembah Pantai, WPKL May 2014)
Surat sokongan dari KKM
Sokongan YBMK terhadap kawalan kawasan lapangan
Cadangan MAEH diterimapakai
Kelebihan sampingan
• Kawalan semulajadi dalam rantaian makanan.
• Penghijauan dan pengindahan bandar
amalan pertanian di bandar
perseimbangan ekosistem tempatan
perkayaan biodiversiti
Penjimatan Kos.Kesudahan Kempen Kebersihan dan Anti Nyamuk Kebangsaan 1998 (inisiatif KPKT)
1998 = 27,381 kes
1999 = 10,146 kes
Pengurangan = 17,235 kes
penurunan 63 %
Kos @ RM 4,000 setiap kes
17,235 kes = RM 68,940,000 (penjimatan)
0
10000
20000
30000
40000
50000
60000
70000
80000
90000
100000
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Intensive Campaign
Intensive Campaign
National Cleanliness and Anti Mosquito Campaign
Bersih & Indah Campaign
@10 % reduction in cases per annum
Actual Cases for 2012
Kesudahan kempen kebersihan kawasan terbuka
(ramalan @ 10% pengurangan kes tahunan)
? lives & cost savings
Actual Cases for 2003
Actual Cases in 2013
Predicted 2014 cases (381 cases)
100,661 (190) @ 13/12/14
289,827,708
4+dekad kejadian denggi
12,077 20,973
143,262
372,224
43,346
100,661
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
1973-
1982
1983-
1992
1993-
2002
2003-
2012
2013 2014
Total cases
173.7%
683.1%
Source: MOH Malaysia
220.6%
Kesudahan kempen kebersihan kawasan terbuka(ramalan @ 10% pengurangan kes tahunan)
12077
20973
25807
7905
0
5000
10000
15000
20000
25000
30000
1973-1982 1983-1992 1993-2002 2003-1012
Total cases
173.7%
123%
69.4%
Keberkesanan Kos Pencegahan darisegi pengurangan Keuzuran, Kematian
• Kos minima @ pengurangan 10 % setiap tahun
Pengurusan Kawasan Lapangan melalui
Intervensi Kesihatan Persekitaran
Jumlah kes bagi Dekad ke-3 (2003 - 2012)
dianggarkan menghasilkan hanya 7,905 kes
Berbanding jumlah sebenar 372,224 kes
Pencegahan 364,319 kes = RM 1,457,276,000
Keuzuran = Kehilangan Productiviti
Kematian = Kehilangan Modal Insan
Mengapa “semburan” racunserangga berbahaya dan
kurang berkesan.
Pendedahan kepada karsinogen..Polycyclic Aromatic Hydrocarbons (PAH)
Penggunaan racunkimia selepas 2000.
Actellic EC Sumithion
Fogging membunuh mahkluk lain yang tidak disasarkan.
Kesan sampingan kepada ekosistem
Black arrows indicate live Aedes larvae.
Red arrow indicates dead spider and an unidentified insect.
A pair of dead butterflies
Chua, et al.3 2003
Kesan sampingan kepada ekosistem
A dead frog found in an ovitrap48 hours after application of ULV
A dead centipete and various other spiders and insects found in another ovitrap after application of ULV
Tanpa pemangsa…
• Se ekor nyamuk betina Stegomyia mampumenghasilkan 1,000 biji telur dalam jangkahayat30 hari.
• 500 ekor nyamuk betina = 500,000 biji telur.
• 250,000 ekor = 250,000,000 biji telur.
• 125,000,000 ekor = 125,000,000,000 telur.
Mengurangkan pendedahan kepadagigitan nyamuk
Penggunaan penghalau nyamuk ketika Piala Dunia*
The soccer World Cup, which runs through July 13, has brought thousands of visitors to a country with
the world’s largest incidence of dengue. A heatwave has extended the mosquito season and fans have
been urged to use repellent and wear long-sleeved clothing in the early morning and late afternoon.
* Makiko Kitamura and Natasha Khan – Bloomberg News Jul 1, 2014 4:54 PM
Terima kasih atas
perhatian anda.
Veeramohan Supramaniam, FRSH
HP: 013-3335361, 018-5711371