Report on the Situation of Malaria in the Americas – 2017

1 Document prepared by the Regional Malaria Program, Pan American Health Organization with data from Annual

Country Reports- 2017

Report on the Situation of Malaria in the Americas – 201712

General situation in endemic countriesThe last decade shows an overall downward trend of malaria morbidityand mortality rates in the Region of the Americas (Fig. 1). There wereapproximately 7,500 fewer confirmed cases of malaria between 2007and 2017. Excluding Venezuela, in the same period, malaria-relateddeaths also decreased by almost half from 170 in 2007 to 88 in 2017(Fig. 1). Almost half of the endemic countries showed at least 75%reduction in morbidity, while 35% showed a minimum of 35% reduction(Fig. 2). In 2017, there were approximately 108 million people at risk ofmalaria. Despite the overall trending decline in the number of cases anddeaths, the last three years showed a steady increase in the number ofmalaria cases (Fig. 1). The rise is attributed to the increase in thenumber of cases in Venezuela, Nicaragua, Brazil, and Guyana (Table1).

Five-year snapshot: 2013 - 2017: Over 93% of all malaria in theAmericas was concentrated in six countries: Brazil, Colombia, Guyana,Haiti, Peru and Venezuela. In the same period, 17 of the 21 endemiccountries showed a minimum of a one-third reduction in indigenouscases, including high burden countries such as Haiti and Colombia.Meanwhile, 10 of the countries (Belize, Costa Rica, El Salvador,Honduras, French Guiana, Dominican Republic, Ecuador, andGuatemala) reported decreases above 75% in the incidence ofindigenous cases in that period. This shows that these countries areprogressing and are on track to achieving the goals of the GlobalTechnical Strategy for Malaria by 2020. However, there is a threat of notachieving the goals in Peru, Guyana, Nicaragua, and Venezuela due toincreases in malaria (Fig. 2).

Paraguay and Argentina have reported zero indigenous cases ofmalaria since 2011 and 2012, respectively. Paraguay has also reportedno imported cases in 2017. The latest malaria outbreaks in Paraguayoccurred in the departments of Canindeyu (2007) and Alto Paraná(2009). The 17 malaria cases detected in Argentina in 2017 wereimported cases from countries in the Americas and Africa. In 2016,Argentina and Paraguay officially requested the WHO to begin themalaria elimination certification process in their territories and they areon track for the certification. For Argentina to remain on track to receivethe elimination certification, it must maintain its epidemiologicalsurveillance efforts for timely event identification for new cases from theBolivian territory. The endemic municipality of Yacuiba in borderingBolivia is of particular interest as it has shown an increase from 15 in2014 to 104 in 2017.

In the past five years, Venezuela and Nicaragua increased by almost530% and 917% respectively, with the significant increase taking placein the last three years (2015-2017; Table 2.). Costa Rica reportedindigenous cases for the second year in a row since 2015— 4 in 2016and 12 in 2017. The 2017 cases were recorded in the cantons of SanCarlos (6 cases), Matina (3 cases), and Sarapiqui (3 cases). Thedetection of cases in these districts highlights the risk ofre-establishment of transmission in areas where ecological conditionspersist.

Paraguay

Belize

Costa Rica

Argentina

El Salvador

Honduras

*Fr. Guiana

**Dom. Re..

Ecuador

Guatemala

Bolivia

Mexico

Brazil

Colombia

Suriname

Panama

Haiti

Peru

Guyana

Nicaragua

Venezuela

-100%

-75%

-50%

-25%

0%

25%

50%

75%

100%

Precentage change

893%

707%

Figure 2. Decrease in malaria morbidity by countries ofthe Americas, 2007 - 2017

* French Guiana ** Dominican Republic

>75% Decrease

50-75% Decrease

<50% Decrease

Increase

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

0.0M

0.2M

0.4M

0.6M

0.8M

Confirmed cases [in millions]

0

100

200

300

400

Deaths

Figure 1. Malaria morbidity and mortality inthe Americas, 2007 - 2017

Confirmed Cases

Deaths

P. falciparum & mixed

Between 2016 and 2017: Between 2016 and 2017, the Region of theAmericas observed a 26% rise in malaria (from 569,203 to 776,444).Seven countries reported an increase in indigenous malaria cases from2016 to 2017: Brazil, French Guiana, Guyana, Mexico, Nicaragua, andVenezuela. The increase in cases in Venezuela and Nicaragua continueto be significant (Fig. 2). However, the overall increase in cases in theAmericas is largely due to increases in malaria transmission in Brazil,Nicaragua and Venezuela (Table 1.). Despite the rising malaria cases,there was a downward trend in the morbidity rates of countries thatgenerally tend to have high burden of the disease (Bolivia, Colombia,Guatemala, Haiti, Honduras, and Peru).

In 2017, Venezuela saw a 171% percent increase in confirmed casesfrom the previous year and accounted for over half of the cases in theAmericas. Almost all of these cases were indigenous and were reportedin 16 out of the 23 states, with Bolivar state accounting for three-fourthsof total cases in the country. Of those identified, P. vivax accounted fortwo-thirds of the cases while the rest of the infections were due to P.falciparum (15%) and mixed infections (5%).

In particular, the cases in Bolivar state were limited to Sifontesmunicipality, where one-third of all cases in the country wereconcentrated. Despite the total population of Sifontes beingapproximately 50,000, they reported around 120,000 cases, whichshows the magnitude of the transmission with people getting multipleinfections in a year. Also, large migrations of unaccounted people to thearea for mining increased the proportion of miners with malaria by 30%(36,376) from the previous year. The movement of the population fromother states and countries to Sifontes due to the illegal mining boom hasencouraged these people to settle in places with conditions conducivefor malaria transmission. In turn, both the United Nations (UN) and theWorld Bank agree that Venezuela is going through a complex situationdue to social, political, and economic problems.

Suriname is well on its way to eliminating local transmission of malariaby 2020 through the implementation of its National Malaria EliminationStrategy. Forty indigenous malaria cases were reported in 2017compared to 1756 in 2010. In 2017, almost 70% of all cases were foundamong males between the ages of 15 and 59, demonstrating the strongassociation of malaria risk to economic activity. As such, Suriname’ssuccess is the result of proactive and innovative interventions thatprimarily focused on areas and communities at risk, such as peopleengaged in informal and small-scale mining operations as well as thosethat serve the miners. Suriname can help strengthen regional efforts bystrengthening surveillance and control measures and sharing its lessonslearnt with neighboring Brazil, Guyana, and French Guiana.

Between 2014 and 2017, Peru reduced the number of malaria cases bymore than 15% (from 65,252 to 55,367 cases). The Ministry of Health ofPeru approved the "Malaria Zero Plan" in 2017 with the objective ofeliminating malaria in the Amazon region of Peru, particularly in Loretodepartment which had 96% of all cases in 2017.

Most of the cases were located in districts with a large proportion ofethnicities.

1


Country Year Total Cases CasesInvestigated Imported Indigenous-fal..Imported-falci.. Imported-vivax Active Foci

Argentina 201520162017

Belize 201520162017

Costa Rica 201520162017

Ecuador 201520162017

El Salvador 201520162017

Mexico 201520162017

Paraguay 201520162017

Suriname 201520162017

000

624

833

000

1711

1778

17711

3211

114

100

000

214

9513

9513

310

564

734

734

1398

25138

25138

62320

4814241

559118

309403184

10523359

1,3801,424686

1,3801,424686

064

317

000

000

317

4149

4149

464350

153127

11146

000

294534

765596551

765596551

000

332

232

000

5108

500

5108

19279147170

1139491

1617

511251295

433327376

551327376

Table 2. Malaria in countries of E2020 in the Region of the Americas, 2015 - 2017

Blank cells and "..." imply no data available

Country Year Total Popn at Risk Blood SlidesExamined Confirmed Cases P. falciparum &

mixed infections SPR API

Bolivia 201520162017

Brazil 201520162017

Colombia 201520162017

DominicanRepublic

201520162017

FrenchGuiana

201520162017

Guatemala 201520162017

Guyana 201520162017

Haiti 201520162017

Honduras 201520162017

Nicaragua 201520162017

Panama 201520162017

Peru 201520162017

Venezuela 201520162017

1.011.221.52

3.023.574.34

4996

4,5875,5536,907

151,697155,407159,167

4,549,2154,549,2154,549,215

5.123.865.52

11.469.479.00

20,93315,29716,743

194,370129,246143,161

1,656,4281,341,6441,573,538

37,954,00433,469,32325,933,921

5.017.715.49

21.2828.1117.01

30,92550,09832,363

54,10283,22755,866

244,732242,973316,451

10,792,29510,792,29510,176,936

0.070.140.10

0.150.200.18

370722651

398755661

226,988280,124316,947

5,625,2275,549,4996,319,676

5.581.893.17

2.743.75

848091

597258434

...9,43011,558

107,020136,388136,831

0.470.44

1.011.461.88

5451

3,7444,8545,540

372,158333,535295,246

...10,361,23012,600,000

18.5514.8513.02

13.929.557.51

6,1174,5473,950

13,93611,1089,984

100,096110,891132,941

751,223747,884767,000

1.632.231.72

6.487.095.81

2,11921,43017,583

19,13521,43017,583

62,53961,21069,659

11,741,2369,600,39510,243,693

0.160.520.63

0.782.242.32

1291,351933

1,2874,0973,575

148,160167,836150,854

8,055,6037,897,9685,717,174

4.452.280.65

1.651.130.38

1,8691,311345

10,9496,2842,307

660,452553,615604,418

2,461,5412,762,1323,523,063

1.021.120.78

1.801.600.87

6386

689811562

38,27050,77264,511

673,330725,253717,489

14.4117.3014.96

13.7510.007.69

13,32115,31913,682

55,36756,62366,609

388,699566,230865,980

3,843,3373,273,8974,453,082

25.0722.6422.38

36.2126.0122.07

96,10161,61535,967

414,527242,561137,996

1,144,635852,556625,174

16,537,06310,712,8236,165,291

Table 1. Malaria in countries in the Region of the Americas, 2015 - 2017

2


Distribution of bed nets in Peru has not taken place since 2016, andalthough the number of households sprayed increased from 7,581 in2016 to 15,865 in 2017, the open nature of people’s homes in Loreto -especially those in Andoas - makes it difficult to spray houses. The planaims to address the lack of access to diagnosis and treatment as well asthe coverage of preventive measures that puts them on the path tomalaria elimination.

Honduras reported less cases in 2017, as compared to 2015 and 2016(Table 1). The decline in cases is potentially associated with the reportedconsolidation of jellyfish fishing from the coastal areas of Gracias a Diosin Honduras to Puerto Cabezas along the Nicaraguan Caribbean coastalstrip. Although there was little difference between the P. vivax cases,Honduras showed a 90% decrease in P. falciparum cases between 2016and 2017. Also, Gracias a Dios showed a 75% decrease in P. vivaxcases. Furthermore, improved access to bed nets, and prompt diagnosisand treatment and investment in surveillance is contributing to thereduction of malaria cases. There is an increase in the number of casesbeing investigated, as well as an improvement in quality of theinvestigations.

Plasmodium speciesAlthough there are five parasite species, four species of plasmodia affectpeople (P. vivax, P. falciparum, P. malariae and P. ovale). Plasmodiumvivax and P. falciparum have the highest prevalence in the world andpose the greatest threat. Unlike P. falciparum, P. vivax manages topersist in latent state for months or even years in the liver of infectedpeople and cause a relapse. In this sense, the training of health systemspersonnel, responsible for the identification of the plasmodium species,is a fundamental component for the understanding of the epidemiology ofthe disease.

In 2017, P. vivax (75%) and P. falciparum (20%) caused the cases in theAmericas. P. falciparum made up almost all of the infections in theDominican Republic and Haiti. Despite the increase in cases inNicaragua and Venezuela, there is a decrease in proportion of cases dueto P. falciparum and mixed infections.

In the Americas, P. vivax has the highest incidence and is responsible foralmost two-thirds of the infections registered between 2013 and 2017.During this period of time, all indigenous cases reported by Belize, CostaRica, El Salvador and Mexico were caused by P. vivax. Furthermore,only four cases of P. falciparum cases were reported in Bolivia comparedto 959 in 2013.

Malaria cases by sex and ageBetween 2013 and 2017, six out of every 10 cases reported in theAmericas occurred in men. During the same period, the majority ofcases in the Americas were reported among those aged 15-19 and20-24 years (Fig. 3). In 2017, the proportion of cases in men was thesame as 2016 and slightly lower than in 2013 (Fig. 3).

In Suriname and Venezuela, those aged 15-49 accounted for over half ofall cases demonstrating a strong association of malaria risk and illegaland informal mining in 2017 (Fig. 4). The following nine countriesaccounted for a significant portion of the total number of cases reportedfor those aged 14 and below: Bolivia, Brazil, Colombia, Guatemala,Guyana, Haiti, Nicaragua, Peru, and Venezuela (Fig. 4). This suggeststhat a significant fraction of the malaria transmission of in these countriesoccurs within the household.

AmazonasIn 2017, the 25 municipalities with the highest malaria burden in theAmazonas reported over half of the total cases in the Americas (Fig. 5).Compared to the previous year, malaria increases were observed in 24out of the 25 municipalities in 2017. The 25 municipalities arerepresented by six states in three countries, with Venezuela (17) havingthe highest number of municipalities, followed by Brazil (7) and Peru (1).The malaria cases in these 17 municipalities in Venezuela combinedaccounted for half of the cases in the Americas, while 20% of all thecases occurred in Sifontes of Bolivar State. As a result of an outbreak,the combined cases in Bermudez, Cajigal, Benitez, Ribero, and Marinomunicipalities in Sucre state represented 10% of the total cases amongthese high burden municipalities. Malaria continues to increase inSifontes and extend to neighboring municipalities such as El Callao dueto the persistence of illegal mining and associated social conflicts. Theseand other persistent factors have compromised the efficiency ofdistribution of supplies as well as the coverage of vector control activitiesthat aim to reduce malaria. ..

<5 5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50+

010,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

Confirmed Cases

Figure 3. Malaria by age group and sex, 2017

*Data provided by Haiti is excluded due to methods of reporting

Female Male

0% 20% 40% 60% 80% 100%Confirmed Cases

Peru

Panama

Ecuador

Haiti

Belize

Brazil

Mexico

Honduras

*Fr. Guiana

Colombia

Nicaragua

Guyana

Bolivia

Guatemala

Venezuela

**Dom. Rep.

Argentina

Costa Rica

Suriname

El Salvador 100%

13%

14%

13%

15%

33%

11%

12%

20%

70%

10%

14%

13%

10%

13%

11%

14%

10%

16%

37%

49%

45%

48%

44%

56%

49%

63%

68%

59%

61%

73%

62%

62%

71%

11%

81%

84%

94%

35%

23%

35%

24%

11%

23%

30%

22%

17%

24%

24%

13%

22%

25%

13%

7%

6%

9%

8%

8%

7%

6%

7%

6%

9%

8%

8%

7%

6%

6%

6%

Figure 4. Malaria Cases by Age group and Country, 2017

*French Guiana **Domincan Republic

Age GroupLess than 5 years

5 to 14 years

15 to 49 years

50 and above

Sixteen of the 25 municipalities with the highest cases in 2016 werealso among the top 25 municipalities in 2017. The other nine that areno longer in the top 25 municipalities include Quibdo, San JuanBautista,Casacoima, Tigre, Rodrigues Alves, Napo, Atabapo, Bolivar,and Alto Baudo. The following nine municipalities were among the 25municipalities in 2017, but not 2016: Bermudez, Cajigal, Barcelos,Santa Isabel, Bagre, Autana, Manapiare, Ribero, and Marino.

Although Gran Sabana is among the top 25 municipalities for bothyears, it showed a 40% reduction, while Quibdo was no longer amongthe top 25 municipalities after reducing two-thirds of its cases. Andoaswas no longer considered among the top 10 (of the 25) municipalitiesbetween 2016 and 2017 due to an increase in cases in othermunicipalities. Sifontes is the municipality with the most cases in bothyears, while malaria in Atures has also increased exponentially owingto low coverage of preventive interventions.

3


Municipality State Country

0 100,000

20150 200,000

20160 200,000

2017

Sifontes Bolivar VenezuelaAtures Amazonas VenezuelaEl Callao Bolivar VenezuelaCruzeiro do Sul Acre BrazilCaroni Bolivar VenezuelaCedeno Bolivar VenezuelaSucre Bolivar VenezuelaManaus Amazonas Brazil*Sao Gabriel Amazonas BrazilRaul Leoni Bolivar VenezuelaAndoas Loreto Peru**Andres Eloy Sucre VenezuelaPiar Bolivar VenezuelaMancio Lima Acre BrazilBermudez Sucre VenezuelaGran Sabana Bolivar VenezuelaCajigal Sucre VenezuelaBarcelos Amazonas Brazil***Santa Isabel Amazonas BrazilBenitez Sucre VenezuelaBagre Para BrazilAutana Amazonas VenezuelaManapiare Amazonas VenezuelaRibero Sucre VenezuelaMarino Sucre Venezuela

71,934

9,812

4,462

14,979

922

6,898

3,820

9,748

5,071

7,777

7,898

774

2,115

5,552

57

8,354

46

4,207

1,608

935

3,528

3,091

413

13

102,543

12,856

11,135

20,591

9,004

11,727

8,944

9,699

10,415

11,250

10,112

5,047

5,447

7,885

2,496

15,662

889

3,865

3,348

6,104

129

3,802

3,234

1,997

571

142,267

46,725

38,230

21,322

17,789

14,600

13,628

13,596

12,274

11,338

10,744

10,142

9,509

9,290

9,242

8,996

8,884

8,129

7,581

7,517

6,793

6,139

6,126

5,988

5,871

Figure 5. Municipalities (ADM-2) with high malaria burden incountries of the Amazonas sub-region, 2015 - 2017

* São Gabriel da Cachoeira **Andres Eloy Blanco, ***Santa Isabel do Rio NegroDistrict-level data (ADM-3) used for Peru, which were partially available during 2015-2017.

MesoamericaIn 2017, the 25 municipalities with the highest burden ofdisease in Mesoamerica reported a 20% increase from theprevious year (Fig. 6). Fifteen of the 25 municipalities showedan increase in malaria. Municipalities in Gracias a Dios stateof Honduras have shown significant decrease. Themunicipalities (Puerto Lempira and Sonaguera) that accountedfor over 50% of all cases in Honduras in 2016 reduced theircases by at least three-fourths in 2017. The following fourmunicipalities in Guatemala: La Gomera, Tiquisate, andMasagua reported at least a one-fourth reduction since 2016.

La Gomera, which exhibited a significant increase of cases in2015 was able to decrease malaria cases through thereinforcement of epidemiological surveillance efforts. Alongwith Guatemala, the malaria reduction in Honduras andPanama exhibits the impact of the readjustment of activities,such as better access to diagnosis and treatment throughvolunteer collaborators using RDT and mass distribution ofbed nets.

Fifteen of the 25 municipalities with the highest cases in 2016were also among the top 25 municipalities in 2017. Thefollowing 10 municipalities were among the top 25 in 2016, butnot in 2017: Tocoa, Brus Laguna, La democracia, VilledaMorales, Olanchito, Santa Catalina, Puerto Barrios,Chiquimulilla, Desembocadura, and Fray Bartolome de lasCasa.

Although malaria seems to have halved in El Progreso,transmission continues to occur in farms and communities ofmunicipalities in the bordering state of Cortes. The slightincrease in Guna Yala is related to passive surveillance withintroduction of RDT for use by community health workers.Siuna municipality, which was not among the top 25 in 2016,was among the top five (of the 25) municipalities with the mostcases in 2017 due to an outbreak, which may be linked to theexpanding risk of malaria from the neighboring municipality ofRosita. Although, Roatan showed decline of malaria mainlydue to prevention activities and supervision of the diagnosisand treatment network, it experienced an outbreak in 2017.

HispaniolaThe municipalities with the highest burden of malaria arerepresented by Haiti. Seven municipalities (Les Irois, LesAnglais, Port-a-Piment, Jeremie, Anse d’Hainault, DameMarie, and Roseaux) made up almost half of the total cases inHaiti (Fig. 8). Eleven of the 25 municipalities show a decliningtrend in 2017.

Eighteen of the 25 municipalities with the highest cases in2016 were also among the top 25 municipalities in 2017 forthe island of Hispaniola. The municipalities of Arnaud Nippes,Carrefour, Leogane, Ganthier, Arcahaie, and Gressie wereamong the 25 municipalities with the highest burden in 2016,but not in 2017. The following five municipalities were amongthe 25 municipalities in 2017, but not 2016: Baraderes Nippes,Cavaillon, Anse a Veau, Torbeck, and Petite Riviere deNippes.

In 2017, there were outbreaks in the municipalities of Les Iroisand Port-a-Piment that increased malaria cases by 50% and98% respectively (Fig. 8). Croix-Des-Bouquets, Delmas, andPort-au-Prince reduced their cases by more than half in 2017,removing them from the top 10 municipalities.

As for the Dominican Republic, malaria is currently almostexclusively limited to shanty towns settled on the border ofrivers in Santo Domingo

Vector Control InterventionsIn 2017, just over 726,207 homes and 1.6 million people wereprotected through indoor residual spraying (IRS). Meanwhile,another 4.7 million were protected with insecticide-treated bednets (ITNs). In recent years, coverage by IRS has decreased.Between 2016 and 2017 the number of people protected byIRS was reduced by 22%, while that by ITNs increased by12%.


0 2,000

20150 2,000

20160 10,000

2017

Puerto Cabezas *RACCN NicaraguaLa Gomera Escuintla GuatemalaRosita *RACCN NicaraguaWaspan *RACCN NicaraguaSiuna *RACCN NicaraguaMasagua Escuintla GuatemalaTiquisate Escuintla GuatemalaPrinzapolka *RACCN NicaraguaPuerto Lempira Gracias A DiosHondurasEl Estor Izabal Guatemala**Santa Lucia Escuintla GuatemalaGuna Yala Guna Yala PanamaPanzos Alta Verapaz GuatemalaRoatan ***Islas De La HondurasChepo Panama PanamaEl Progreso Yoro HondurasBonanza *RACCN NicaraguaBatopilas Chihuahua MexicoChisec Alta Verapaz Guatemala****Nueva ConceEscuintla Guatemala*****Santa Cata Alta Verapaz GuatemalaSitala Chiapas MexicoSonaguera Colon HondurasChilon Chiapas MexicoSanta Catalina Ngobe-Bugle Panama

673

1,935

340

414

45

807

424

393

954

301

246

200

453

88

136

191

42

16

128

86

59

12

167

17

34

1,309

1,655

818

441

14

565

615

74

1,854

235

211

270

172

150

216

273

55

26

38

84

29

52

274

30

107

7,954

1,253

1,151

710

362

359

317

315

314

301

300

300

234

217

142

136

126

114

105

100

90

85

82

80

77

Figure 6. Municipalities (ADM-2) with high malaria burden incountries of the Mesoamerican sub-region, 2015 - 2017

*RACCN- North Caribbean Coast Autonomous Region, ** Santa Lucia Cotzumalguapa, ***Islasde la Bahia, ****Nueva Concepcion, *****Santa Catalina la Tinta

Change from previous yearDecrease Increase


4


Figure 7. Malaria by Annual Parasite Index (API) at the second administrative level (ADM-2) in the Americas - 2017

Between 2016 and 2017, Venezuela, Brazil, Colombia, Panama, andthe Dominican Republic were the countries that reported the greatestdeclines in coverage by IRS.

Among these countries, Venezuela showed the most drastic reductions(99%), compared to 2015 and 87% compared to 2016. Bolivia’s 2017policy adoption included free distribution of ITNs/LLINs to all agegroups and through mass campaigns. Furthermore, IRS isrecommended by the malaria control program. Bolivia, along withCosta Rica, Nicaragua, and Peru exhibited the most importantincreases in IRS coverage. In particular, there was an 80% increase inIRS in Nicaragua largely due to an organized response to the outbreakin Puerto Cabezas.

Resistance to insecticidesIn 2017, the structure of the Americas Network for Surveillance andInsecticide Resistance Management led to more countries developingtheir surveillance and management plans for insecticide resistance forAnopheles than previous years. The following 13 endemic countriesare in the development phase of their respective plans (Brazil, Bolivia,Colombia, Costa Rica, Dominican Republic, Ecuador, Guatemala,Guyana, Haiti, Honduras, Mexico, Nicaragua, and Paraguay).

Meanwhile, Argentina, Panama, Peru, and Suriname are in the initialconsultation stages of their entomological surveillance and insecticideresistance management plans. Although Panama and Suriname havenot begun their development of the plans, they expressed their desireto comply with the policies and strategic frameworks surroundingmalaria. In 2017, Costa Rica, Guatemala, Colombia, Honduras, andFrench Guiana carried out sensitivity tests on Anopheles.

Diagnosis and treatmentThe diagnosis and timely treatment are paramount for malaria control.In 2017, the uptake of rapid diagnostic tests for malaria (RDT)performed in endemic countries continued to expand by more than100,000, compared to 2012 (from 220,529 to 364,878). Thisdemonstrates the adoption of the strategy at the national and regionallevel as well as a possible improvement in access to diagnosis.

The proportion of cases treated within the first 72 hours after the onsetof symptoms exceeded 70%, as reported by Bolivia, Brazil, Ecuador,Peru, and Suriname (Fig. 9).


02,000

20150 4,000

20160 2,000

2017

Les Irois Grand-Anse Haiti

Les Anglais Sud Haiti

Port-a-Piment Sud Haiti

Jeremie Grand-Anse Haiti

Anse d'Hainault Grand-Anse Haiti

Dame-Marie Grand-Anse Haiti

Roseaux Grand-Anse Haiti

Bonbon Grand-Anse Haiti

Abricots Grand-Anse Haiti

Corail Grand-Anse Haiti

Croix-Des-BouquetsOuest Haiti

Verrettes Artibonite Haiti

Baraderes Nippes Haiti

Tiburon Sud Haiti

Chardonnieres Sud Haiti

Port-Salut Sud Haiti

Delmas Ouest Haiti

Les Cayes Sud Haiti

St. Louis du Sud Sud Haiti

Port-au-Prince Ouest Haiti

Pestel Grand-Anse Haiti

Cavaillon Sud Haiti

Anse a Veau Nippes Haiti

Torbeck Sud Haiti

*Petite Riviere de Nippes Haiti

365

371

71

1,801

777

1,332

1,183

53

282

433

1,077

113

105

131

124

42

1,628

90

10

659

336

171

33

13

11

781

1,238

107

2,029

1,462

1,746

1,981

222

606

417

1,468

299

104

335

280

234

831

316

537

562

499

63

32

65

37

1,500

1,493

1,392

1,358

1,320

1,112

798

635

588

526

412

398

395

366

360

353

334

301

283

259

254

238

210

200

142

Figure 8. Municipalities (ADM-2) with high malaria burdenin countries of the Island of Hispaniola, 2015 - 2017

*Petite Riviere de NippesData at commune level used for Haiti


5


Nonetheless, it is likely due to confusion on the part of the countriesthat report the time elapsed between sampling (not since the onset ofsymptoms) and start of treatment. Strengthening the capacities ofnational programs to maximize the supply of inputs to combat malariais a prerequisite for adequate access to diagnosis and antimalarialtreatments.

Vulnerable populationsBetween 2013 and 2017, people who are living in conditions ofvulnerability saw a significant increase in cases. During this period, aone-fourth increase was observed among pregnant women andindigenous populations. Nicaragua and Venezuela presented thehighest number of cases among pregnant women. During the sameperiod, eight of the endemic countries showed a decrease. With33,103 cases, Venezuela presented the highest number of cases inindigenous people among the endemic countries in 2017, a 50%increase since 2013. Guatemala, Haiti, Honduras, and Panama haveimproved the quality of data on pregnant women while Peru needs tocontinue improvement. In many malaria endemic countries, poor anddisadvantaged people with limited access to health facilities andtreatments are disproportionately affected by the disease. Atures inAmazonas State, where the indigenous people live, was hit hard bycases of malaria, with fourfold increase in cases.

One-third of the cases in miners were found in countries within theGuiana Shield (Fig. 10). Since miners search for gold in watery pits,which serve as breeding grounds for mosquitos, tens of thousands ofillegal miners contract the disease. The economic activity thatpromoted migration and to Bolívar state from other states hasresulted in the rapid spread of the disease among the indigenouspeople who come in contact with the miners and those living in otherstates as the miners return to their homes.

The proportion of cases among miners in Suriname decreased by80% between 2013 (629 cases) and 2017 (134). In 2017, one-fourthof the total cases were among miners. Suriname is showing progressthrough the Ministry of Health Malaria Programme, which targetsvulnerable populations such as mobile migrant gold miners. Theprogramme provides malaria services in a migrant clinic inParamaribo, operates a small number of border malaria-screeningposts along the border with French Guiana, maintains a malariaservice deliverer (MSD) network in gold-mining areas, performs activecase detection surveys in remote mining areas, and implementsMalakit- an innovative pilot project used for self-diagnosis andself-treatment.

Cases imported from malaria in endemic countriesIn 2017, 8,411 imported cases were reported by 14 of the endemiccountries in the Americas. One-third of these cases occurred inVenezuela (2,941) while Brazil accounted for almost two-thirds of theinfections. During the same period, almost all of the imported cases(7,686) in the Americas originated in four countries (Venezuela,Guyana, Colombia, and Peru). Brazil reported the largest number ofcases detected in its territory imported from other countries (4,148cases).

FinancingMost of the budget for malaria control the Americas between 2013and 2017 came from national government resources. During thisperiod, the government invested just over 900 million dollars,representing approximately two-thirds of total financing in theAmericas (Fig. 12). Between 2013 and 2017, eight countries (Bolivia,Brazil, Colombia, Costa Rica, Dominican Republic, El Salvador,Panama, and Suriname) showed a decline in malaria funding fromthe national government. Ecuador showed a 71% decline between2016 (US $20,000,000) and 2017 (US $5,835,716). This is due to theearthquake response in Ecuador in 2016 and the ensuing increase invector control budget; budget for only malaria control is difficult toestimate in integrated vector control programmes.

Between 2012 and 2017 the investment from the United States Aidfor International Development and the Global Fund to Fight AIDS,Tuberculosis and Malaria for the Americas amounted toapproximately US $ 140 million (Fig. 12). In 2017, governmentfunding reached US $ 145 million, which was 70% of the total budgetfor that year, slightly lower than in 2016. Seven endemic countries(Brazil, Colombia, Guatemala, Guyana, Nicaragua, Paraguay, andPeru) increased their government budget in 2017 compared to 2016.

Country P. vivax P. falciparumArgentinaBelizeBoliviaBrazilColombiaCosta RicaDominican RepublicEcuadorEl SalvadorFrench GuianaGuatemalaGuyanaHaitiHondurasMexicoNicaraguaPanamaParaguayPeruSurinameVenezuela

PQ+CQ(7d)

CQ+PQ(14d)CQ+PQ(14d)

CQ+PQ(14d)

CQ+PQ(14d)CQ+PQ(14d)CQ+PQ(14d)CQ+PQ(14d)

CQ+PQ(14d)

CQ+PQ(14d)

CQ+PQ(14d)

CQ+PQ(14d)

CQ+PQ(7d);CQ+PQ(14d)



CQ+PQ(7d)

CQ+PQ(7d)

CQ+PQ(7d)

CQ+PQ(3d)

CQ+PQ(1d)

CQ+PQ(1d)CQ+PQ(1d)

CQ+PQ(1d)CQ+PQ(1d)

CQ+PQ(1d)

CQ+PQCQ+PQ

CQ+PQ

CQ+PQ

AS+PQ(1d)

AS+MQ+PQ(1d)AL+PQ(1d)

AL+PQ(1d)

AL+PQ(1d)

AL+PQ(1d)AL+PQ;AS+MQ+PQ

AL+PQ

AL+PQ

AL+PQ

AL+MQ,CL,DO

AL;AQ+PGAL

Table 3. First line of treatment for malaria by species type inthe Región of the Américas

CQ- Chloroquine PQ- Primaquine MQ- Mefloquine AS- Artesunate AL- Artemether &Lumefantrine AQ- Atovaquone CL- Clindamycin DO- Doxycycline

For P. falciparum- (3d): 15 mg of Primaquine per day for 3 days (adults) (1d): 45 mg of Primaquine in one dose on 1st day (adults)

For P. vivax- (14): 15 mg of Primaquine per day for 14 days (adults) (7): 30 mg of Primaquine per day for 3 days (adults)* Artemisinin-based combination therapy (ACT) is used for imported cases of P.falciparum in countries using CQ as first-line treatment for this species.

Country 2015 2016 2017

25% 50% 75%

% of all cases25% 50% 75%

% of all cases25% 50% 75%

% of all cases

Argentina

Belize

Bolivia

Brazil

Colombia

Costa Rica

*Dom.Rep.

Ecuador

El Salvador

**Fr. Guiana

Guatemala

Guyana

Haiti

Honduras

Mexico

Nicaragua

Panama

Paraguay

Peru

Suriname

Venezuela

Figure 9. Time taken for treatment since the onset ofsymptoms, 2015 - 2017

*Dominican Republic **French Guiana

Time takenSame day

1 day

2-3 days

Less than 3 days

>3 days

6


Figure 10. Malaria in Vulnerable Populations

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

0M

50M

100M

150M

200M

250M

US$ [in millions]

Figure 12. Financing for malaria, 2007 - 2017

*Data unavailable for Costa Rica and Ecuador (2014), French Guiana (2007-13 &2017), Guatemala (2009 & 2010), Haiti (2007-11), Honduras (2015), Nicaragua(2009), Peru (2009 & 2014), Suriname (2007, 2009-17) and Venezuela (2007-08 &2017).

Funding SourceBilaterals

GFATM

USAID

UN Agencies

World Bank

Gov. budget

Country Miners

0% 50% 100%

Total Cases

Argentina

Belize

Bolivia

Brazil

Colombia

Costa Rica

*Dom. Rep.

Ecuador

El Salvador

**Fr. Guiana

Guatemala

Guyana

Haiti

Honduras

Mexico

Nicaragua

Panama

Paraguay

Peru

Suriname

Venezuela

Miners (2017)

* Dominican Republic **French Guiana

Miners Others

2016 2017

2.00 4.00Relative Risk

2.00 4.00Relative Risk

0.00

1.63

0.50

0.00

0.37

1.65

2.45

0.15

1.09

0.58

1.53

0.30

5.40

0.32

0.00

0.53

0.48

0.28

0.00

0.00

0.96

1.69

0.79

2.60

1.02

1.86

0.00

0.86

1.23

0.91

0.91

0.21

1.57

0.87

0.42

0.31

0.71

Pregnant Women2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

0M

2M

4M

6M

8M

10M

People protected [in millions]

Figure 11. People protected by Indoor Residual Spraying(IRS) and Insecticide-Treated Nets (ITNs), 2007 - 2017

People protected by IRS

People protected by ITNs

However, there were increases in malaria in three of these sevencountries: Brazil, Guyana, and Nicaragua.

In contrast, during 2017, government funding declined in Bolivia,Costa Rica, Dominican Republic, Mexico, Panama, and Surinamefrom the previous year. Despite the steady decrease in funding in thelast five years (US $ 787,966 in 2013 and US $451,993 in 2017),Bolivia exhibited a 20% decline in confirmed cases. In order tocontinue its commitment to providing free malaria prevention tools tominers and other hard-to-reach and mobile populations, Surinamemust increase its government contribution for its elimination strategyas funding has been steadily declining since 2013.

7


Malaria in non-endemic countriesGeneral situation of non-endemic countriesIn 2017, 19 of the 32 of the non-endemic countries in the Americas reported a total of 106 cases of malaria and no associated deaths werereported, excluding the United States and Canada (Table 4). Cuba (36) and Uruguay (23) reported the highest number of malaria cases amongthe non-endemic nations of the Americas.

Large number of imported cases from Guyana and Venezuela were reported in Cuba. Seven of the cases reported in Uruguay were importedfrom the Americas, mainly Brazil. Increased imported cases from Honduras to the Cayman Islands may be due to the availability of direct flightservices that connects both countries.

Almost all of the imported cases in Trinidad and Tobago (11 out of 12 cases), were from Venezuela. Due to the geographical proximity, Trinidadand Tobago is a convenient destination where Venezuelan migrants go to for various reasons. The risk of having re-established malariatransmission in this country remains high and calls for robust surveillance. Of the total cases in non-endemic countries reported between 2015and 2017, almost half were caused by P. falciparum and mixed infections, and the species is unknown in almost 10% of the cases.

Sudan

Equatorial Guinea

South Sudan

Mozambique

South Africa

Ivory Coast

Philippines

Nicaragua

Colombia

Pakistan

Panama

Senegal

GuyanaUganda

Guinea

Mexico

Nigeria

Angola

GabonCongo

Brazil

Chad

India

Peru

Haiti

Figure 13. Malaria by country from which cases were imported by non-endemic countries in the Region of the Americas, 2015 - 2017

* Does not include cases reported imported by Canada & United States of America.

Import RegionAmericas

Asia

Africa

Number of cases0

50

100

134

8


CountryYear

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017AnguillaAntigua & BarbudaArubaBahamasBarbadosBermudaBonaireBritish Virgin IslandsCanadaCayman IslandsChileCubaCuraçaoDominicaGrenadaGuadeloupeJamaicaMartiniqueMonteserratPuerto RicoSabaSaint BarthelemySaint Kitts & NevisSaint LuciaSaint Martin*Saint Vincent & the GSint MaartenTrinidad & TobagoUnited States of AmericaUruguayUS Virgin IslandsGrand Total 1,964

023

1,744120

1

00

8

00036211

114

02

200

2,774014

2,053

0

01

04

2320107181

612

2

000

2,14607

1,51780

01

05

4411002985

5520

22000

2,24402

1,725120

01

01

5

10

3740

4490

223

0

2,340013

1,74113

010

1096221

486

4900

52

00

2,26407

1,68719

01201

1025210

32103

480

92

00

2,54002

1,92510

0711

20139101

2851

517

106

10

2,2730

1,69123

21

1

50712801

31

5140

21

1

1,92405

1,48424

2110

301122010

4

364

2

00

1,798012

1,29822

1

0

201422120

19

3810

14

10

2,1660

1,50516

0

0

3

199

00

355

397

6

Table 4. Number of malaria cases in non-endemic countries of the the Region of the Americas, 2007 - 2017

*Saint Vincent & the Grenadines **Blank spaces imply no data available ***Preliminary data from Canada for 2016 & 2017 and from USA for 2017

Africa

Asia

Oceania

Unknown

2

35

138

7

294

2,8675

1

1

113

1

4

8111

1

994

1

11

25

255

2

3111

*Central America, Unspecified

1 2,867Other Regions

Country/Regionfrom which malariawas imported

Country / Territory

Antigua &

Barbuda

Bahamas

Barbados

Bermuda

Canada

Cayman

Islands

Chile

Cuba

Dominica

Grenada

Guadeloupe

Jamaica

Martinique

Puerto Rico

Saint Lucia

Trinidad &

Tobago

U.S.A.

Uruguay

Bahamas

Brazil

Colombia

Dominican Republic

El Salvador

Guatemala

Guyana

Haiti

Honduras

Jamaica

Mexico

Nicaragua

Panama

Peru

Venezuela

Trinidad

*Central America, unsp

1

1

1

1

3

10

3

22

1

1

3

15

33

19

25

1

42

5

11

1

11

2

0

1

2

1

1

1

000

8

1

1

3

16

1

3

1

2

4

1

2

3

2

1

4

6

4

2

3

1

1

1

0

Table 5. Imported cases in non-endemic countries of the Americas by country / Region of origin, 2015 - 2017

* U.S.A. - United States ofAmerica

1 42Countries of Americas

9


Report on the Situation of Malaria in the Americas – 2017

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