ISPOR 15th Annual European Congress

3-7 November 2012

ICC Berlin, Berlin, Germany
Presentation Code: PRS10
POSTER SESSION V Wednesday, 7 November 2012
08:45 - 14:45

AN ANALYSIS OF REPORTED PNEUMONIA

DEATHS IN MALAYSIA
Azmi S1, Abdul Aziz SH1, Goh A1
HEALTH . RESEARCH . SOLUTIONS
1
Azmi Burhani Consulting Sdn Bhd, Petaling Jaya, Selangor, Malaysia

1. introduction The proportion of pneumonia deaths in the older population (aged 65 and above)
increased from 2004 to 2008.
Annually there are an estimated 25 million pneumonia cases worldwide and
Figure 2: Distribution of pneumonia death by age group (%), 2004-2008
63,500 deaths. According to the World Health Organization (WHO), pneumonia is
also the leading cause of death in children.1
According to the Department of Statistics Malaysia (DOSM), pneumonia is one of
the top ve causes of death in Malaysia.2 In 2009, pneumonia was the 4th leading 50.8% 52.2% 53.2% 54.4% 55.7%

cause of death in Ministry of Health (MOH) Hospitals in Malaysia (10.4% of

hospital mortality).2
In Asia, Streptococcus pneumoniae (S. pneumonia) is one of the main pathogens 24.9% 25.0% 24.6% 25.9% 26.4%
that cause pneumonia. Other leading causes include Haemophilus inuenzae,
Staphylococcus aureus and Klebsiella pneumonia.3
12.4% 11.7% 11.2% 10.3% 9.3%

A recent study estimated that routine vaccination with a Heptavalent }11.9% }11.1% }11.0% } 9.4% } 8.6%
Pneumococcal Conjugate Vaccine (PCV7) of one years birth cohort in Malaysia
would be expected to prevent 2,289 cases of all cause pneumonia and reduce
paediatric mortality by 336 deaths.4
Pneumonia mortality rates vary by country.5 Due to vaccination, developed
countries have been reported to have a decreasing pattern of pneumonia6 while There was an increasing trend of pneumonia deaths as a proportion of all cause
death rates attributed to pneumonia for developing countries is still not well death from 2004 to 2008 (Figure 3).
established. Time-series regression indicated that the increasing proportion of pneumonia deaths
To the best of our knowledge, the mortality rate caused by pneumonia in relative to all cause death during 2004-2008 was statistically signicant (p=0.006).
Malaysia has not been described. Age groups 31-45 (p=0.008), 46-64 (p=0.011) and greater than 65 (p=0.005)
This study sought to describe pneumonia deaths rate and its trends in Malaysia
contributed to the increasing pattern of death attributed to pneumonia in our study.
from 2004 to 2008.
Figure 3: Percentage of deaths caused by pneumonia compared to all cause
2. Methodology death
p=0.006

Data on all cause and pneumonia deaths in Malaysia from year 2004 to 2008
were obtained from the DOSM. For death attributed to pneumonia, the data
p=0.005
obtained included the age, year and cause of death. Data on all cause death was
given for each year, though the age and cause of death were not provided. p=0.011

The DOSM data on pneumonia deaths was based on death records obtained p=0.008

from the Malaysian National Registration Department. These were categorised p>0.005

using the International Statistical Classication of Diseases and related Health

Problems, Tenth Revision (ICD-10).
Deaths caused by pneumonia were identied by ICD-10 codes J18 and J23 in the
data provided by DOSM.
Death rate was reported in deaths per 100,000 population.

All cause death

All cause death rate = X 100, 000
Malaysian population

Deaths attritubed to pneumonia

4. discussion
Pneumonia crude death rate = X 100, 000
Malaysian population Deaths due to pneumonia appear to show an increasing trend over the period from
2004 to 2008 relative to the all cause death rate during that time.
Analysis was conducted using Microsoft Oce Excel 2007 and Stata SE version The result is consistent with other studies that reported age group 65 and above
11.2. contributes to a signicant portion of pneumonia deaths. Dierent from previous
studies, our study shows age groups 31-45 and 46-64 are also contributing to the

3. results
increased pneumonia deaths.7,8
The trend of increasing pneumonia deaths could be related to factors such as:
As shown in Table 1, the all cause death rate in Malaysia ranged from 440.41 to 453.99 o Over-prescription of antibiotics which lead to higher pathogen resistance
per 100,000 population from 2004 to 2008. o Increasing number of migrants from less developed countries
Deaths attributed to pneumonia ranged from 11.93 to 19.29 per 100,000 population in o Improvements in cause of death reporting and identication of pneumonia as a
the same period. cause of death
Death rate attributed to pneumonia showed an increasing trend (Figure 1). o Our study is reliant on the presumed accuracy of the ICD-10 coding provided
within the dataset. Related to this, we believe that cases of tuberculosis related
Table 1: All cause death and pneumonia death rate by year (2004-08)
to pneumonia may explain part of the increasing trend
All cause Pneumonia Authors recognize limitations of this study as the data that was used was limited in its
Malaysian depth. In particular, the data provided did not have date or location of death. Hence,
Pneumonia death rate (per death rate
Year All cause death Population
death 100,000 (per 100,000 our analysis was unable to assess monthly or seasonal variation. Also unknown is
('000)
population) population)
whether the pneumonia deaths were hospital acquired or community acquired
2004 112,700 3,052 25,590 440.41 11.93
2005 113,714 3,366 26,100 435.69 12.90 pneumonia.
2006 115,084 3,656 26,584 432.91 13.75
2007 118,167 4,222 27,051 436.83 15.61
2008 124,857 5,306 27,502 453.99 19.29
Total (2004-08)/
Death rate
584,522 19,602 132,827 440.06 14.76 5. CONCLUSION
Our study shows an increasing number of deaths in Malaysia caused by pneumonia
Figure 1: Pneumonia death rate (per 100,000 population) from 2004 to 2008 between 2004-2008. The rate of pneumonia deaths has increased signicantly when
compared against all cause mortality.
We would aim to collaborate further with the DOSM to obtain greater details in the
dataset to gain better clarity of these ndings.
For future study, further examination of pathogenic causes as well as wide scale
surveillance of pneumonia in Malaysia is needed.
The additional study would help to determine the validity of these ndings and
understand the reasons for this possible increasing trend.

6. acknowledgement
The authors wish to thank the Department of Statistics Malaysia for providing the
data used in this study.

Abbreviations: DOSM=Department of Statistics Malaysia; ICD-10=International Statistical Classication of Diseases and related Health Problems, Tenth Revision; MOH=Ministry of Health; PCV7=Heptavalent
Pneumococcal Conjugate Vaccine; S. pneumonia=Streptococcus pneumonia; WHO=World Health Organization Corresponding authors email: soraya.azmi@azmi-burhani.com

References:
1. World Health Organization. Pneumonia Factsheet N0331, August 2012;
[http://www.who.int/mediacentre/factsheets/fs331/en/] (Accessed on 22 October 2012).
2. Ministry of Health Malaysia: Health Facts 2009.
[http://www.moh.gov.my/images/gallery/stats/heal_fact/healthfact-P_2009.pdf]. (Accessed on 17 October 2012).
3. Song JH. Epidemiology and clinical outcomes of community acquired pneumonia in adult patients in Asian countries: a
prospective study by the Asian network for surveillance of resistant pathogens. Int J Antimicrob Agents 2008, 31:107-114.
4. Aljunid S, Abuduxike G, Ahmed Z, Sulong S, Nur AM, Goh A. Impact of routine PCV7 (Prevenar) vaccination of infants on
the clinical and economic burden of pneumococcal disease in Malaysia. BMC Infectious Diseases 2011, 11:248.
5. World Life Expectancy. [http://www.worldlifeexpectancy.com/world-rankings-total-deaths#instructions]. (Accessed on 22
October 2012).
6. Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, et al. Global, regional, and national causes of child mortality: an
updated systematic analysis for 2010 with time trends since 2000. Lancet 2012, 379:2151.
7. World Health Organization Statistics. Mortality Database.
[http://apps.who.int/whosis/database/mort/table1_process.cfm.] (Accessed on 13 June 2012).
8. HealthyHK, Department of Health, Hong Kong: Health Facts 2009
[http://www.healthyhk.gov.hk/phisweb/en/healthy_facts/disease_burden/major_causes_death/pneumonia/] (Accessed
on 25 October 2012.