PREFACE
This is the third issue of the series on State of Malaysian Children, the first in 1999 and the second 2001 in an attempt to present to the professionals involved in the care of children the quality of services, especially medical, now being provided in this country. In an attempt to collect information for this issue, we have come up with a very difficult situation in that, for the most recent data required (i.e. for the Year 2004), discrete individual information on mortality data usually through the National Statistics Department were not available. As such, mortality obtained from the Ministry of Health hospital admissions was utilized.
Professor Datuk Dr. Mohd Sham Kasim
Editor
STATE OF MALAYSIAN CHILDREN
Prof Datuk Dr Mohd Sham Kasim
Introduction
Malaysia is geographically situated in the middle of South-East Asia consisting of the peninsula forming the Southern-most point of the Asian mainland and the northern part of the island of Borneo. In 2004, the population of the country was 25.58 millions and with a total land mass of 330, 434 square kilometers, the population density of the country was 74.4 persons per square kilometer. 80% of the population resided in Peninsular Malaysia, whilst 11.2% were domiciled in Sabah and 8.9% in Sarawak respectively. (Table I)
Table I: Land Aarea and Population Of Malaysia (2004)
Malaysia / Peninsular Malaysia / Sabah / SarawakTotal Area (330,434) / 131,529 / 73,700 / 125,205
Total Population (25,580,100 / 20,455,100 / 2,862,300 / 2,262, 700
Population Density (Persons per sq km)(77.4) / 155.5 / 38.8 / 18.1
Source: Vital Statistics, Malaysia
The population is truly cosmopolitan in nature consisting of the majority Malay and other ethnic groups on the island of Borneo, Chinese and Indians (Table II). In terms of their religious upbringing, the Malays are Moslems, the Chinese are Buddhists and the Indians Hindus.
Table II: Malaysian Ethnic Groups (2004)
Population / PercentageMalaysia (Total) (‘000) / 25,580.9 / 100
Malays & other Bumiputras (‘000) / 15,701.4 / 61.4
Chinese (‘000) / 6,074.6 / 23.8
Indians (‘000) / 1,806.8 / 7.1
Others (‘000) / 304.3 / 1.2
Non-Malaysian Citizens (‘000) / 1,693.8 / 6.6
Source: Vital Statistics, Malaysia
The Under-5 population is 2,738,000 which is 10.7% of the total population; while the Under-15 population was 5,797,000, 22.7% of the population. Table III below shows the steady decrease of percentages of both the under-5 and the Under-15 Populations from 1990 to 2004 due to the declining birth rates. Thus, the under-5 population had decreased from 13.3 percent in 1990 to10.7% in 2004. Similarly, the Under-15 population had decreased from 36.2 percent in 1990 to 32.9% in 2004.
Table III: Under-5 and Under-15 Populations of Malaysia from 1990 to 2004
Year / 1990(Percentage)* / 1995
(Percentage) / 2000
(Percentage) / 2004 (Percentage)
Total population (‘000) / 14,619(100) / 20,108(100) / 23,494(100) / 25,580(100)
Under-5 population(‘000) / 1,948(13.3) / 2510(12.5) / 2,833(12.1) / 2,738(10.7)
Under-15 population(‘000) / 5294(36.2) / 7147(35.5) / 8,003(34.1) / 8,414(32.9)
Source: Vital Statistics, Malaysia * Refers only to Peninsular Malaysia
Survival
The life expectancy of the population at birth was 73.3 years (M=70.4, F=76.2) in (2004). There has been a steady improvement from 71.3 in 1990, 71.7 in 1995 and 72.5 in 2000.
The child (Under 18 –year) population is 9,529,000, 39.8% of the population and this puts Malaysia as having a high proportion of young people. This places Malaysia in second place in this region behind the Philippines where children form 42.2% of the population.(Table IV)
In 2004, 549,000 children were born giving a crude birth rate (CBR) of 23 per 1000 population showing a steady declining from 28.4 per 1000 in 1990 to 25.6 in 2000. It is still relatively high when compared to other countries in the region. The crude death rate (CDR) has not changed significantly from 4.7 per 1000 in 1990 to 4.7 in 2000 and 5.0 per 1000 in 2004. The annual population growth rate is 2.4 per year placing it among the highest in the region (Philippines=2.1, Vietnam=1.6)
Table IV: Demographic Indicators of Malaysia Compared to Individual Countries (Year 2004)
Indicator / Malaysia / Thailand / Indonesia / Singapore / Philippines / Japan / USA / UK% of Under-18 Population / 39.8 / 31.7 / 32.3 / 24.2 / 42.2 / 17.9 / 25.7 / 22.6
Crude Birth Rate(CBR) / 23 / 18 / 21 / 9 / 25 / 9 / 13 / 11
Annual Pop. Growth Rate / 2.2 / 1.4 / 2.1 / 2.5 / 2.1 / 0.3 / 1.0 / 0.3
Source: The State of the World’s Children, 2004
Table V shows the Infant Mortality Rates (IMR) and the Under-5 Mortality Rates(U-5MR) through the last 20 years for Malaysia. The IMR in 2004 was 5.4 per 1000 live births. It was 23.8 in 1980, then 13.1 in 1990 and 6.8 in 2000. Similarly, the U-5 M R, at present 6.2 were 25.7 in 1980 and 14.1 in 1990. The IMR and U-5MR of neighbouring and some developed countries are given in Table VI below for comparison.
Table V: Change of Infant Mortality Rate (IMR) and Under-5 Mortality Rate (U-5MR) for Malaysia
Indicator / 1980 / 1990 / 1995 / 2000 / 2004IMR / 23.8 / 13.1 / 10.4 / 6.8 / 5.4
U-5MR / 25.7 / 14.1 / 11.2 / 7.3 / 6.2
Source: From Vital Statistics, Malaysia
Table VI: Malaysian Infant Mortality Rate (IMR) and Under-5 Mortality Rate (U-5MR) Compared to Other Countries (2004)
Indicator / Malaysia / Indonesia / Thailand / Philippines / Japan / USA / S’pore / AustraliaIMR / 5.4 / 30 / 18 / 26 / 3 / 7 / 3 / 5
U-5MR / 6.2 / 38 / 21 / 34 / 4 / 8 / 3 / 6
Source: The State of the World’s Children, 2004
In terms of disease burden, admissions to the Ministry of Health Hospitals will reflect on the disease load suffered by the Malaysian population. The Table below gives the leading causes of diseases suffered by infants. The most frequent cause of admission was neonatal jaundice accounting for 36.5% of admissions, followed by pneumonia at 4.9%, then Preterm/low birth weight (4.8%), birth asphyxia/ aspiration/birth trauma (3.5%) and congenital malformations (3.3%). Table VII
Table VII: Leading Causes of Ministry of Health Hospital Admissions, age < 1 year, 2004
Perinatal Conditions
q Preterm, low birth weight
q Neonatal Jaundice
q Birth Asphyxia, Neonatal aspiration, Birthtrauma
q Chromosomal abn., cong. Malform.
Infections
q Acute Gastroenteritis
q Pneumonia
q Acute bronchiolitis
q Septicaemia
q Bacterial Meningitis
q DF & DHF
q Measles
q Acute Pharyngitis & Tonsilitis
Neoplastic Diseases
Anaemia, Thalassaemia
Epilepsy & Status Epilepticus
Asthma
Injuries,Burns
Total / 3
1
5
4
12
3
2
6
8
9
14
13
10
17
16
15
11
7 / 8349
62665
6057
5735
5763
8390
5025
1191
1032
288
421
1013
457
224
270
740
1752
171806 / 4.9
36.5
3.5
3.3
3.4
4.8
2.9
0.7
0.6
0.12
0.24
5.9
2.6
1.3
1.6
2.3
10.2
100
Source: Technical Report of Director-General of Health, Malaysia
However, the most frequent causes of infant deaths were preterm/low birth weight (24.2%), followed by congenital malformations, chromosomal abnormalities (17.7%), neonatal infections (9.2%), and birth asphyxia/ aspiration syndrome (9.1%)(Table VIII). The causes of death in the last 20 years are shown in Table IX . Thus for the year 1980, even though perinatal conditions were the most frequent cause of death, infective and parasitic diseases and diarrhoeal diseases were also important causes.
Table VIII: Medically Certified Deaths in Ministry of Health Hospitals (<1 year, 2004)
Neonatal Problems
o Preterm, low birth weight
o Neonatal Infections
o Birth Asphyxia, aspiration syndrome
o Respiratory Distress Syndrome
o Neonatal Jaundice
Congenital malformations, chromosomal abn.
Homicide and other traumas
Infections
q Septicaemia
q Pneumonia
q Gastroenteritis
q Meningitis
Malignancies
Others
Total / 1421 (46.3)
729 (24.2)
282 (9.2)
278 (9.1)
97 (3.2)
35 (1.1)
545 (17.7)
20 (0.7)
253 (8.2)
92 (3.1)
12 (0.4)
48 (1.6)
15 (0.5)
665 (21.7)
3071 (100)
Source: Technical report of the Director-General of Health, Malaysia, 2004, Ministry of Health Malaysia.
For those 1-4 years old, the most frequent cause of admission was acute gastroenteritis (24.9%) followed by anaemia/thalassaemia (20%), pneumonia (17.7%), injuries (12.2%), and asthma (10.8%).(Table X) This shows the very heavy disease load of acute gastroenteritis often of viral etiology. Similarly, transfusion-dependent thalassaemics, 150 of whom are born yearly in Malaysia, are admitted regularly every 4 to 6 weeks for their blood transfusions.
Table X: Leading Causes of Ministry of Health Hospital Admissions, age 1 - 4 years, 2004
Rank / Discharges / %Infections
q Acute gastroenteritis
q Pneumonia
q Acute bronchiolitis
q Measles
q Malaria
Injuries
Haemoglobinopathies
Asthma
Neoplastic Diseases
o Leukaemia
Total / 1
3
7
9
10
4
2
5
6
8 / 9477
6773
1760
700
435
4677
7992
4135
2280
1066
38229 / 24.8
17.7
4.6
1.8
1.1
12.2
20.
10.8
6.0
2.7
100
Sources: Technical Report of the Director-General of Health ,Malaysia 2004
Table XI shows the leading causes of deaths in the 1-4 year age group, which are infectious diseases in the form of septicaemia, pneumonia, encephalitis and bacterial meningitis. Trauma, either accidental or inflicted, is the next most frequent cause of death and this is followed by malignant disease. This mortality pattern is different from that of developed countries where trauma is the most frequent cause of death, followed by malignant disease and then only by infection.
When the leading causes of death are looked at through the years (Table XII), it can be seen that acute gastroenteritis and diarrhoea and infectious diseases were major causes of death in1980 but not later on.
Source: Vital Statistics, Malaysia
For children 5-11 years old, the most frequent causes of admission were injuries/poisoning (20.7%), haemoglobinopathies (11.7%), genito-urinary disorders (7.1%), intestinal infectious diseases (5.2%) and asthma (4.7%). Table XIII. This again shows the importance of trauma as the major disease burden. The leading causes of deaths in those children 5-11 years old were injuries (18%), septicaemia (17.3%), pneumonia (9%), malignancy (9%) and bacterial meningitis (3%).(Table XIV). As a significant proportion of children would have died at the site of injury, such as in burns, drowning or traffic accidents, they would not have been admitted to hospital and thus missed being recorded.
Table XIII: Top Diagnosis Groups for Inpatients in Ministry of Health hospitals (5-9 Years old) in 2004
Diagnosis Group / Admissions(%)Injury, Poisoning
Haemoglobinopathies
Genito-urinary disorders (mainly UTI, nephritis,
nephrotic syndrome
Intestinal infectious disease
Asthma
Other gastrointestinal and liver disorders
DF & DHF
Childhood neoplasms including leukaemia
Pneumonia
Diseases of the nervous system
Congenital anomalies
Septicaemias
Total Admissions / 17612(20.7)
9661(11.7)
6074(7.1)
4449(5.2)
4014(47.2)
3969(4.7)
3528(4.1)
3055(3.6)
2289(2.7)
2285(2.7)
1682(2.0)
233(0.3)
5080 (100)
Source: Report of Morbidity & Mortality of Inpatients in MOH Hospitals
Table XIV: Medically Certified Deaths in Ministry of Health Hospitals (5-11 years old) 2004
Infectious Diseases
o Septicaemia
o pneumonia
o encephalitis
o Bacterial Meningitis
Congenital malformations
Trauma(Total)
q Fractures
q Intracranial Injuries
q Burns & Corrosives
q Others not classified
Malignancies
o leukaemia
Total / 78
38
11
12
10
81
8
19
4
38
37
450 / 17.3
9
3
3
3
18
9
100
Source: Technical Report of Director-General of Health Malaysia
Source: Vital Statistics Malaysia
For those children 12-19 years old, the most frequent cause of admission was injury/poisoning (27.85), followed by gastrointestinal and liver disorders (7%), haemoglobinopathies (6.1%) and genito-urinary disorders (5.1%).
Table XVI:Top Diagnosis Groups for In-patients in Ministry of Health Hospitals (12-19 Years old) in 2004
Diagnosis Group / Admissions (%)1
2
3
4
5
6
7
8
9
10
11
12
13 / Injury, Poisoning
Gastrointestinal and liver disorders
Haemoglobinopathies
Genito-urinary disorders (mainly UTI, nephritis,
nephrotic syndrome
Diseases of the nervous system
Asthma
Intestinal infectious disease
Childhood neoplasms including leukaemia
Congenital anomalies
Pneumonia
TB
DF &DHF
Septicaemias
Total / 37597(27.8)
9496(7.0)
8207(6.1)
6871(5.1)
2504(1.9)
1981(1.5)
1667(1.2)
2699(1.9)
996(0.7)
984(0.7)
594(0.4)
477(0.4)
378(0.3)
135333(100)
Source:Report of Morbidity & Mortality of In-patients in MOH Hospitals,2004
For those 12-19 years, the most frequent cause of death is again trauma, followed by septicaemia, malignancy, pneumonia and thalassaemia.
Table XVII: Medically Certified Deaths in Ministry of Health Hospitals 12-19 years old, 2004)
Total / No. / PercentageInjuries
Septicaemia
Neoplasms
Pneumonia
Thalassaemia
Rheumatic fever
Acute & chronic renal failure
Encephalitis
DF & DHF
Meningitis
Congenital malformations
TB
Others
Total / 372
138
89
51
21
19
18
15
13
12
10
10
367
1135 / 32.8
12.7
7.9
4.5
1.9
1.7
1.6
1.3
1.1
1.1
0.9
0.9
32.2
100
Source: Report of Morbidity and mortality of In-Patients in Ministry of Health hospitals, 2004
Table XVIII: 5 Leading Causes of Death for Children 15 - 19 years of age, in order of frequency *Refers to patients aged 12-19 Years
Rank / 1980 / 1985 / 1990 / 1995 / 2000 / 2004*1. / Accidents other than MVA / Violence / Violence / MVA / MVA
(665) / Trauma
2. / Violence / Accidents / MVA / Violence / Cardiov
Disease
(87) / Septicaemia
3. / MVA / MVA / Accidents other that MVA / Accidents other than MVA / Pneumo.
& resp D.
(63) / Malignancy
4. / Malignant neoplasma inc. leukemia. / Disease of circ. Sys. / Disease of circ. Sys. / Disease of circ. Sys. / Malign
Neoplasm
(60) / Pneumonia
5. / Chronic rheumatic heart disease / Malignant neoplasma inc. leukemia / Malignant neoplasma inc. leukemia / Malignant neoplasma incleukemia / Septicae
(55) / Thalassaemia
Source: Vital Statistics, Malaysia
Table XIX showed those who were injured because of accidents on the road. The major cause was among the motor cyclists and their pillion riders in both having to be admitted to hospital and in mortality.