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EPIDEMIOLOGY
OF DISEASES IN
MALAYSIA
Epidemiology of diseases in Malaysia
Epidemiology of diseases in Malaysia
Epidemiology of diseases in Malaysia
Epidemiology of diseases in Malaysia
Epidemiology of diseases in Malaysia
Epidemiology of diseases in Malaysia
Epidemiology of diseases in Malaysia
VPDS (VACCINE
PREVENTABLE DISEASES )

• All infectious diseases which can be prevented
  by vaccines are on a downward trend, in line
  with the national and WHO target.
• No cases of polio, neonatal tetanus and
  diphtheria.
• No large epidemics
• Measles and hepatitis B under control and on a
  downward trend.
Epidemiology of diseases in Malaysia
Childhood Immunisation Coverage, Malaysia 2003
BCG                                99.00%
Triple & Double Antigen (3rd Dose) 85.40%
Polio Immunisation (3rd Dose)      94.90%
Measles Immunisation               75.50%
Hep B Immunisation (3rd Dose)      93.10%
Epidemiology of diseases in Malaysia
Epidemiology of diseases in Malaysia
WATER & FOOD BORNE
DISEASES
• A drop in the incidence rate of food and
  water borne diseases such as typhoid,
  cholera, para typhoid, hepatitis A and
  dysentry since 10 years ago (1988-1997)
• Related to improvement of safe water
  supply and better sanitation.
• However there is an increase of food
  poisoning incidence.
Epidemiology of diseases in Malaysia
CHOLERA
• Still a public health problem especially in
  Sabah and the northern peninsular.
• Related to the use of contaminated water
  during drought or water shortage.
• Sabah - GREG storm 1997
• Sarawak – use of contaminated rain water
TYPHOID
• Occurs in some states especially
  Kelantan, Sabah and Terengganu.
• Big outbreak in Tawau 1997 due to the
  use of contaminated river water (180
  cases)
• Outbreak in Kota Baru, Kelantan
  believed to be related to “sirap ais”.
HEPATITIS A
• Endemic in some states such as
  Terengganu, Kelantan and Sabah.


DYSENTRY
• Most cases occurs at border areas in
  Sabah, Sarawak, Kedah, Perlis, Perak
  and Johor.
FOOD POISONING
• A big problem in institutions, schools
  and factories.
• Related to unhygienic food
  preparation.
• Mostly due to E. coli, Salmonella spp
  and Staphyllococcus aureus.
AIDS/HIV
Epidemiology of diseases in Malaysia
AIDS
• Abbreviation for Acquired Immune
  Deficiency Syndrome.
• Infected persons will lose their natural
  immune defence system and minor
  infections will become life threatening
  diseases.
• This person will usually die from serious
  opportunistic infection or due to rare
  cancers.
The Virus
• Identified in 1983/84.
• In 1986, given the name Human Immuno-
  deficiency Virus (HIV) by ICTV.
• It is a retrovirus that belongs to a large
  family of RNA lentiviruses.
• 2 types identified
  – HIV-1,
  – HIV-2.
Epidemiology of HIV/AIDS
• Currently more than 34.3 million people
  with HIV worldwide.
• Malaysia –
  – No cases before 1986
  – end of 2003, 58012 accumulated cases.
• Malaysia majority are IDU’s, male &
  Malays.
HIV/ AIDS
• Infected newborns - increasing
• Infected prostitutes - increasing
• Heterosexual transmission more nowadays
• Infection rate amongst blood donors ( 0.03-
  0.06%)
• Sentinel surveillance sentinel – no obvious
  trend
HIV and AIDS Estimates for the Western Pacific Region, 1999
                    Estimated HIV   Estimated HIV     Estimated
  Country/area       prevalence     prevalence rate     AIDS           Status of epidemic
                     (age 15-49)      (age 15-49)     incidence
Cambodia               170 000           3.3%          10 000     Stabilizing; heterosexual
                                                                  Expanding in selected areas;
Papua New Guinea       14 000            0.6%            150      heterosexual transmission

Malaysia               50 000            0.4%            900      Stable; mostly IDU

                                                                  Expanding; IDU, heterosexual
Viet Nam               100 000           0.2%           3 700     transmission increasing rapidly
Singapore               3 000            0.1%           >120      Stable

Australia              14 000            0.1%          +/- 200    Declining; mostly homosexual
                                                                  Expanding; mostly IDU;
China                  500 000          <0.1%            n/a      heterosexual increasing
Hong Kong               3 700           <0.1%           +/- 60    Stable

Japan                   8 100           <0.1%          +/- 200    Stable

Lao, PDR                1 400           <0.1%            >50      Stable

New Zealand             1 200           <0.1%           +/- 30    Declining; mostly homosexual

Philippines           +/- 10 000        <0.1%            >50      Slowly expanding; heterosexual

Korea, Republic         3 800           <0.1%           +/- 30    stable

Total                 >876 200          <0.1%         >>15 490
Trends in HIV/AIDS Reported
                       Selected countries 1989-1998
 HIV/AIDS cases reported
                                New Zealand
 9 000                          Australia
                                Hong Kong
 8 000                          Japan
 7 000                          S. Korea
                                Singapore
 6 000                          Malaysia
                                Cambodia
 5 000                          Vietnam
 4 000
 3 000
 2 000
 1 000
     0
110418   89       90       91     92    93    94   95   96   97   98
Trends in AIDS Reported Cases
                 Selected countries 1989-1998
   AIDS cases reported
                                             New Zealand
                                             Australia
1 600                                        Hong Kong
                                             Japan
1 400                                        S. Korea
                                             Singapore
1 200                                        Malaysia
                                             Cambodia
1 000                                        Vietnam
    800
    600
    400
    200
        0
11050
7           89    90     91   92   93   94   95    96      97   98
Epidemiology of diseases in Malaysia
Epidemiology of diseases in Malaysia
Epidemiology of diseases in Malaysia
Epidemiology of diseases in Malaysia
VECTOR BORNE DISEASES
DENGUE/DHF
• Increasing number of cases and deaths due
  to rapid urbanisation and industrialisation.
• Especially in Kuala Lumpur, Selangor,
  Johor, Perak and Negeri Sembilan (urban
  areas)
• Ratio of DF:DHF are 7-25 : 1
• Fatality rate DHF 0.2-0.4%
Epidemiology of diseases in Malaysia
MALARIA
• Still a major problem in Sabah,
  Pahang, Sarawak, Perak, Kelantan and
  Johor.
• Main Agent - Plasmodium falciparum
• Especially amongst Orang Asli, land
  settlers, soldiers and immigrants.
Epidemiology of diseases in Malaysia
Epidemiology of diseases in Malaysia
TUBERCULOSIS
Increasing trend, >50% new cases are
infectious
New cases - age 21-40 yrs.
-13% are imigrants (50% in Sabah, 15% in
WP,KL)
-cure rate 86% (1997)
Mortality increasing due to late treatment
and HIV/AIDS.
Epidemiology of diseases in Malaysia
Epidemiology of diseases in Malaysia
Survival Functions
               1.2


               1.0


                .8


                                                                            Ujian ELISA
                .6
                                                                                Tidak reaktif
                .4
Cum Survival




                                                                                Tidak reaktif
                                                                                -censored
                .2
                                                                                Reaktif

               0.0                                                              Reaktif-censored
                -200        200         600         1000          1400
                        0         400         800          1200          1600


                     INTERVAL
Epidemiology of diseases in Malaysia
Non-Communicable Disease
Epidemiology of diseases in Malaysia
Common Risk Factors of Lifestyle
          Diseases
  Share Predisposing Conditions:
      – Hypertension
      – Obesity (especially central obesity)
      – Diabetes Mellitus
      – Cancer

  And Common Risk Factors:
     – Tobacco
     – Physical Inactivity
     – Irrational Diet (especially high fat intake)
      – Alcohol over-consumption
Adult Smoking (NHMS 3)
• 27.0% ever smokers
• 21.5% current smokers
• Higher amongst Malay (24.0%), rural
  (32.3%), males (57.6%, females only
  2.5%).
• Higher in Kelantan (31.7%), Pahang
  (29.8%) and Sabah (29.3%). Lowest in
  Penang (20.7%) - NHMS 2
Physical Inactivity
• NHMS 2 (20 minutes/day, 3x a week)
   – 11.6% exercised adequately,
   – 31.7% ever exercised
   – Nearly 70% of Malaysians do not exercise
• NHMS 3 (WHO-stepwise questionnaire, <150
  minutes/week of moderate physical activities & 60
  minute/week of vigorous physical activities)
   – 43.7% physically inactive
   – higher in woman, older age, urban residence,
     unemployed and housewife.
Irrational Diet (NHMS 3)
•   Underweight (BMI <18.5kg/m2) - 8.5%
•   Normal (BMI 18.5-24.9kg/m2) - 48.3%
•   Overweight (BMI 25.0-29.9 kg/m2)-29.1%
•   Obese (BMI 30kg/m2 & >) - 14.1%
•   Overweight in 1996 16.6%, now 29.1%
•   Obese in 1996 4.4%, 2002/2003 12.7% and
    now 14.1%.
Alcohol (NHMS 3)
• 16.2% ever drank              – age group between 70
                                  – 74 years old (10.4%),
• 7.4% current drinkers
                                – Christians (25.6%),
• For current drinker the       – senior officer /
  prevalence was higher           manager (24.8%), and
  in;                           – married (7.9%).
   –   Sarawak state (15.0%),   – tertiary level of
   –   in urban area (8.9%),      education (13.7%).
   –   among males (11.8%),     – earned RM 5000 and
   –   Chinese (23.8%),           above per month
                                  (16.3%)
Major NCD Diseases
• Hypertension - 29.9% 1996, 32.2% in 2006
• Cancer - 31,700 cases a year
• Diabetes Mellitus - 8.3% 1996, 11.6% in
  2006.
• Injury
HYPERTENSION

Increase of cases due to;
•aging
•Smoking habit
•?life stressors
•? Excessive dietary salt intake
HYPERTENSION
• According to NHMS ’2006;
  – Prevalence of 32.2%
     • Self-reported 11.5%
     • Previously undiagnosed 20.7%
• Higher in rural (36.9% vs 29.3%), Malays (33.9%
  vs 32.4% vs 29.4%) >30 yrs, obese/overweight
• Amongst the hypertensive, 35.8% were previously
  diagnosed. Among those who were previously
  diagnosed, 87.7% were on treatment. Of those on
  treatment, only 26.3% of their BP were under
  control.
CANCER

One of 5 main cause of death since 20
years ago.
Incidence -150 per 100,000 pop. (31,700
cases a year), the cases and deaths due to
cancer are on the rise.
Related to lifestyle and the environment.
Burden of Cancer
• Incidence -150 per 100,000 pop. (30,000 case a
  year)
• Prevalence – 90,000
• Incidence expected to rise with an increase of
  aging population.
   – >60 yrs
       • 1957 4.6%
       • 1990 5.7%
       • 2020 9.8%


GCC Lim, 2002. Overview of Cancer in Malaysia. Jpn J Clin Oncology
Incidence by Gender
• No nationwide population-based cancer
  registry. Data based on extrapolation.
• Survey between 1988-1990;
  – Males 56.3 per 100,000
  – Females 56.9 per 100,000
• Penang registry 1994;
  – Males 115.9 per 100,000
  – Females 119.7 per 100,000

GCC Lim, 2002. Overview of Cancer in Malaysia. Jpn J Clin Oncology
Racial Differences
• Noted in NPC & oral cavity cancer
• NPC amongst males by race;
   – Malay 0.79 per 100,000
   – Chinese 15.9 per 100,000
   – Indian 1.1 per 100,000
• NPC amongst females by race;
   – Malay 0.8 per 100,000
   – Chinese 4.1 per 100,000
   – Indian 0 per 100,000
Incidence by Type
Diabetes Mellitus – (NHMS3)
• Overall prevalence was 11.6%. Known
  diabetes was 7.0%. Newly diagnosed
  diabetes was 4.5%.
• Higher in the urban at 12.1% compared to
  the rural areas at 10.5%.
• Between ethnicity, Indians have the highest
  prevalence of 19.9% , followed by Malays
  11.9% and Chinese 11.4%.
Epidemiology of diseases in Malaysia
INJURY

Main cause of death and hospital
admission - MVA & fall.
Upward trend.
Epidemiology of diseases in Malaysia
Epidemiology of diseases in Malaysia
Diseases Due To Migration
Epidemiology of diseases in Malaysia
Epidemiology of diseases in Malaysia
Conclusion

•   Malaysia is a country undergoing a health transition
•   Improving socioeconomic status and aging
    population leads to chronic & degenerative
    diseases. Problems such as;
       Occupational diseases
       Chemical poisoning from industry and agriculture
       Diseases due to air pollution
       Work injury and MVA
       Disease related to urbanisation
•   Trend of disease approaching those of developed
    countries and yet unable to shake off the diseases of
     developing countries. A double burden…………
TERIMA KASIH

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Epidemiology of diseases in Malaysia

  • 9. VPDS (VACCINE PREVENTABLE DISEASES ) • All infectious diseases which can be prevented by vaccines are on a downward trend, in line with the national and WHO target. • No cases of polio, neonatal tetanus and diphtheria. • No large epidemics • Measles and hepatitis B under control and on a downward trend.
  • 11. Childhood Immunisation Coverage, Malaysia 2003 BCG 99.00% Triple & Double Antigen (3rd Dose) 85.40% Polio Immunisation (3rd Dose) 94.90% Measles Immunisation 75.50% Hep B Immunisation (3rd Dose) 93.10%
  • 14. WATER & FOOD BORNE DISEASES • A drop in the incidence rate of food and water borne diseases such as typhoid, cholera, para typhoid, hepatitis A and dysentry since 10 years ago (1988-1997) • Related to improvement of safe water supply and better sanitation. • However there is an increase of food poisoning incidence.
  • 16. CHOLERA • Still a public health problem especially in Sabah and the northern peninsular. • Related to the use of contaminated water during drought or water shortage. • Sabah - GREG storm 1997 • Sarawak – use of contaminated rain water
  • 17. TYPHOID • Occurs in some states especially Kelantan, Sabah and Terengganu. • Big outbreak in Tawau 1997 due to the use of contaminated river water (180 cases) • Outbreak in Kota Baru, Kelantan believed to be related to “sirap ais”.
  • 18. HEPATITIS A • Endemic in some states such as Terengganu, Kelantan and Sabah. DYSENTRY • Most cases occurs at border areas in Sabah, Sarawak, Kedah, Perlis, Perak and Johor.
  • 19. FOOD POISONING • A big problem in institutions, schools and factories. • Related to unhygienic food preparation. • Mostly due to E. coli, Salmonella spp and Staphyllococcus aureus.
  • 22. AIDS • Abbreviation for Acquired Immune Deficiency Syndrome. • Infected persons will lose their natural immune defence system and minor infections will become life threatening diseases. • This person will usually die from serious opportunistic infection or due to rare cancers.
  • 23. The Virus • Identified in 1983/84. • In 1986, given the name Human Immuno- deficiency Virus (HIV) by ICTV. • It is a retrovirus that belongs to a large family of RNA lentiviruses. • 2 types identified – HIV-1, – HIV-2.
  • 24. Epidemiology of HIV/AIDS • Currently more than 34.3 million people with HIV worldwide. • Malaysia – – No cases before 1986 – end of 2003, 58012 accumulated cases. • Malaysia majority are IDU’s, male & Malays.
  • 25. HIV/ AIDS • Infected newborns - increasing • Infected prostitutes - increasing • Heterosexual transmission more nowadays • Infection rate amongst blood donors ( 0.03- 0.06%) • Sentinel surveillance sentinel – no obvious trend
  • 26. HIV and AIDS Estimates for the Western Pacific Region, 1999 Estimated HIV Estimated HIV Estimated Country/area prevalence prevalence rate AIDS Status of epidemic (age 15-49) (age 15-49) incidence Cambodia 170 000 3.3% 10 000 Stabilizing; heterosexual Expanding in selected areas; Papua New Guinea 14 000 0.6% 150 heterosexual transmission Malaysia 50 000 0.4% 900 Stable; mostly IDU Expanding; IDU, heterosexual Viet Nam 100 000 0.2% 3 700 transmission increasing rapidly Singapore 3 000 0.1% >120 Stable Australia 14 000 0.1% +/- 200 Declining; mostly homosexual Expanding; mostly IDU; China 500 000 <0.1% n/a heterosexual increasing Hong Kong 3 700 <0.1% +/- 60 Stable Japan 8 100 <0.1% +/- 200 Stable Lao, PDR 1 400 <0.1% >50 Stable New Zealand 1 200 <0.1% +/- 30 Declining; mostly homosexual Philippines +/- 10 000 <0.1% >50 Slowly expanding; heterosexual Korea, Republic 3 800 <0.1% +/- 30 stable Total >876 200 <0.1% >>15 490
  • 27. Trends in HIV/AIDS Reported Selected countries 1989-1998 HIV/AIDS cases reported New Zealand 9 000 Australia Hong Kong 8 000 Japan 7 000 S. Korea Singapore 6 000 Malaysia Cambodia 5 000 Vietnam 4 000 3 000 2 000 1 000 0 110418 89 90 91 92 93 94 95 96 97 98
  • 28. Trends in AIDS Reported Cases Selected countries 1989-1998 AIDS cases reported New Zealand Australia 1 600 Hong Kong Japan 1 400 S. Korea Singapore 1 200 Malaysia Cambodia 1 000 Vietnam 800 600 400 200 0 11050 7 89 90 91 92 93 94 95 96 97 98
  • 33. VECTOR BORNE DISEASES DENGUE/DHF • Increasing number of cases and deaths due to rapid urbanisation and industrialisation. • Especially in Kuala Lumpur, Selangor, Johor, Perak and Negeri Sembilan (urban areas) • Ratio of DF:DHF are 7-25 : 1 • Fatality rate DHF 0.2-0.4%
  • 35. MALARIA • Still a major problem in Sabah, Pahang, Sarawak, Perak, Kelantan and Johor. • Main Agent - Plasmodium falciparum • Especially amongst Orang Asli, land settlers, soldiers and immigrants.
  • 38. TUBERCULOSIS Increasing trend, >50% new cases are infectious New cases - age 21-40 yrs. -13% are imigrants (50% in Sabah, 15% in WP,KL) -cure rate 86% (1997) Mortality increasing due to late treatment and HIV/AIDS.
  • 41. Survival Functions 1.2 1.0 .8 Ujian ELISA .6 Tidak reaktif .4 Cum Survival Tidak reaktif -censored .2 Reaktif 0.0 Reaktif-censored -200 200 600 1000 1400 0 400 800 1200 1600 INTERVAL
  • 45. Common Risk Factors of Lifestyle Diseases Share Predisposing Conditions: – Hypertension – Obesity (especially central obesity) – Diabetes Mellitus – Cancer And Common Risk Factors: – Tobacco – Physical Inactivity – Irrational Diet (especially high fat intake) – Alcohol over-consumption
  • 46. Adult Smoking (NHMS 3) • 27.0% ever smokers • 21.5% current smokers • Higher amongst Malay (24.0%), rural (32.3%), males (57.6%, females only 2.5%). • Higher in Kelantan (31.7%), Pahang (29.8%) and Sabah (29.3%). Lowest in Penang (20.7%) - NHMS 2
  • 47. Physical Inactivity • NHMS 2 (20 minutes/day, 3x a week) – 11.6% exercised adequately, – 31.7% ever exercised – Nearly 70% of Malaysians do not exercise • NHMS 3 (WHO-stepwise questionnaire, <150 minutes/week of moderate physical activities & 60 minute/week of vigorous physical activities) – 43.7% physically inactive – higher in woman, older age, urban residence, unemployed and housewife.
  • 48. Irrational Diet (NHMS 3) • Underweight (BMI <18.5kg/m2) - 8.5% • Normal (BMI 18.5-24.9kg/m2) - 48.3% • Overweight (BMI 25.0-29.9 kg/m2)-29.1% • Obese (BMI 30kg/m2 & >) - 14.1% • Overweight in 1996 16.6%, now 29.1% • Obese in 1996 4.4%, 2002/2003 12.7% and now 14.1%.
  • 49. Alcohol (NHMS 3) • 16.2% ever drank – age group between 70 – 74 years old (10.4%), • 7.4% current drinkers – Christians (25.6%), • For current drinker the – senior officer / prevalence was higher manager (24.8%), and in; – married (7.9%). – Sarawak state (15.0%), – tertiary level of – in urban area (8.9%), education (13.7%). – among males (11.8%), – earned RM 5000 and – Chinese (23.8%), above per month (16.3%)
  • 50. Major NCD Diseases • Hypertension - 29.9% 1996, 32.2% in 2006 • Cancer - 31,700 cases a year • Diabetes Mellitus - 8.3% 1996, 11.6% in 2006. • Injury
  • 51. HYPERTENSION Increase of cases due to; •aging •Smoking habit •?life stressors •? Excessive dietary salt intake
  • 52. HYPERTENSION • According to NHMS ’2006; – Prevalence of 32.2% • Self-reported 11.5% • Previously undiagnosed 20.7% • Higher in rural (36.9% vs 29.3%), Malays (33.9% vs 32.4% vs 29.4%) >30 yrs, obese/overweight • Amongst the hypertensive, 35.8% were previously diagnosed. Among those who were previously diagnosed, 87.7% were on treatment. Of those on treatment, only 26.3% of their BP were under control.
  • 53. CANCER One of 5 main cause of death since 20 years ago. Incidence -150 per 100,000 pop. (31,700 cases a year), the cases and deaths due to cancer are on the rise. Related to lifestyle and the environment.
  • 54. Burden of Cancer • Incidence -150 per 100,000 pop. (30,000 case a year) • Prevalence – 90,000 • Incidence expected to rise with an increase of aging population. – >60 yrs • 1957 4.6% • 1990 5.7% • 2020 9.8% GCC Lim, 2002. Overview of Cancer in Malaysia. Jpn J Clin Oncology
  • 55. Incidence by Gender • No nationwide population-based cancer registry. Data based on extrapolation. • Survey between 1988-1990; – Males 56.3 per 100,000 – Females 56.9 per 100,000 • Penang registry 1994; – Males 115.9 per 100,000 – Females 119.7 per 100,000 GCC Lim, 2002. Overview of Cancer in Malaysia. Jpn J Clin Oncology
  • 56. Racial Differences • Noted in NPC & oral cavity cancer • NPC amongst males by race; – Malay 0.79 per 100,000 – Chinese 15.9 per 100,000 – Indian 1.1 per 100,000 • NPC amongst females by race; – Malay 0.8 per 100,000 – Chinese 4.1 per 100,000 – Indian 0 per 100,000
  • 58. Diabetes Mellitus – (NHMS3) • Overall prevalence was 11.6%. Known diabetes was 7.0%. Newly diagnosed diabetes was 4.5%. • Higher in the urban at 12.1% compared to the rural areas at 10.5%. • Between ethnicity, Indians have the highest prevalence of 19.9% , followed by Malays 11.9% and Chinese 11.4%.
  • 60. INJURY Main cause of death and hospital admission - MVA & fall. Upward trend.
  • 63. Diseases Due To Migration
  • 66. Conclusion • Malaysia is a country undergoing a health transition • Improving socioeconomic status and aging population leads to chronic & degenerative diseases. Problems such as;  Occupational diseases  Chemical poisoning from industry and agriculture  Diseases due to air pollution  Work injury and MVA  Disease related to urbanisation • Trend of disease approaching those of developed countries and yet unable to shake off the diseases of developing countries. A double burden…………

Notas do Editor

  1. Hipertensi Prevalens hipertensi semakin meningkat di Malaysia. Menurut penemuan awal, prevalens hipertensi dianggarkan 14.7% pada 1980. Kajian dikalangan Orang Melayu di Kuala Selangor, dari 359 sampel yang diperiksa tekanan darahnya 92 atau 25.6% penduduk yang berumur 15 tahun dan keatas mengalami hipertensi (Osman Ali et al. 1984a, Osman ali 1990d). Prevalensnya meningkat menurut umur dan tinggi dikalangan perokok.(jadual 6).
  2. Hipertensi Prevalens hipertensi semakin meningkat di Malaysia. Menurut penemuan awal, prevalens hipertensi dianggarkan 14.7% pada 1980. Kajian dikalangan Orang Melayu di Kuala Selangor, dari 359 sampel yang diperiksa tekanan darahnya 92 atau 25.6% penduduk yang berumur 15 tahun dan keatas mengalami hipertensi (Osman Ali et al. 1984a, Osman ali 1990d). Prevalensnya meningkat menurut umur dan tinggi dikalangan perokok.(jadual 6).
  3. CABARAN MENDATANG AKIBAT PERALIHAN KESIHATAN Corak penyakit yang akan terjadi di negara yang mengalami permodenan pesat seperti Malaysia tidak akan jauh berbeza dengan corak yang telah berlaku di negara maju pada masa kini. Dijangkakan akan terdapat peningkatan berterusan penyakit kardiovaskular, kanser dan injuri dalam tempuh 30 tahun akan datang disebabkan oleh permodenan dan perubahan gaya hidup (first fruit of affluence), kemudian kadar penyakit-penyakit tersebut akan stabil seterusnya menurun akibat meningkatnya pendidikan dan kesedaran tentang kesihatan seperti yang sedang dialami oleh negara-negara maju masa kini (second fruit of affluence)(jadual 14). Selain dari peningkatan sosioekonomi, corak penyakit masa akan datang dipengaruhi oleh umur penduduk memandangkan kadar kematian yang berkurangan dan jangkaan hidup yang bertambah. Lebih ramai penduduk yang akan mencapai umur tua dan sebahagian besar akan mengalami masalah penyakit kronik dan degeneratif seperti kanser, strok, athritis, katarak, dementia dsb (Osman Ali 1995f, Khatijah &amp; Osman Ali 1997).