Brazil has had a significant decrease in malaria morbidity Figure 1. Malaria by Annual Parasite Index (API) at and mortality since 2000. As of 2014, the country municipality level (ADM2), Brazil 2014 officially met the WHA 58.2 target of reducing the malaria Guyana burden by 75%. There were 143,145 confirmed cases of Venezuela Suriname malaria in 2014, a 76.7% decrease from cases reported Colombia in 2000 (Figures 1-2). The number of cases decreased each year during 2011-2014, with an average of 19% decrease for these years. There were also 36 malaria deaths reported for 2014, an 85% decrease from deaths reported in 2000.

Malaria is highly prevalent in the Amazon forest area Brazil

located in the northwestern part of the country (Figure Peru API 1). Incidence of malaria in the Amazon basin accounts per 1,000 people No cases for 99.8% of cases in the country, but only 13% of the Bolivia country’s population lives in this area. Cases from the ≤ 0.1 top 15 municipalities account for 57.3% of all cases in 0.11 - 1 1.01 - 5 the country (Figure 3). Cruzeiro do Sul in state had Paraguay the highest number of cases in 2013 and 2014, though 5.01 - 10 10.01 - 50 there was a 14% decrease in cases between those years. Chile >50

Figure 2. Number of cases and deaths due to malaria Argentina ® Uruguay 0 250 500 1,000 in Brazil, 2000-2014 Kilometers Longitude/Latitude Datum WGS84 Source: PAHO/CHA/VT 600,000 300 Municipalities in the state of Para have had a dramatic s

s e 600,00reduction0 in incidence in recent years following300 an

400,000 200 s

f c a outbreak in 2009. Factors that may have contributed D ea t h

s to the outbreak were limited access to treatment, non- s e 200,000 100 400,00adherence0 to treatment by patients, noncompliance200 s N umber o f c a

of national treatment guidelines, lack of preventionD ea t h

0 0 200,00measures,0 and increased surveillance (23). 100 N umber o

200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 201 3 201 4 The Ministry of Health focused malaria efforts on 5 0 0 P. falciparum & Mixed Confirmed Cases Deaths municipalities (Anajas, Oeiras, Cameta, Curralinho, ■ P. falciparum & mixed ■ Confirmed cases ■ Deaths Jacareacanga, and Itaituba) in Para state, all of which 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 201 3 201 4 P. fahavelciparum decreased & Mixed malariaConfirmed incidence. Cases AnajasDeat hsand Oeiras Municipality State Figure 3. Municipalities with the highest number of municipalities in particular have had a decline of more Cruzeiro do Sul Acre 16,055 20malaria,043 cases in Brazil,17,210 2012-201412.0% than 90% from 2012. Amazonas 9,768 7,295 7,443 17.2% Municipality State Labrea Amazonas 4,068 4,651 7,412 22.4% Cruzeiro do Sul Acre 16,055 20,043 17,210 12.0% Porto Velho Rondonia 15,570 9,134 6,639 27.0% Manaus Amazonas 9,768 7,295 7,443 17.2% Mancio Lima Acre 5,205 7,281 6,207 31.3% Labrea Amazonas 4,068 4,651 7,412 22.4% Eirunepe Amazonas 9,269 8,483 5,288 35.0% Porto Velho Rondonia 15,570 9,134 6,639 27.0% Rodrigues Alves Acre 3,701 3,524 4,774 38.3% Mancio Lima Acre 5,205 7,281 6,207 31.3% Sao Gabriel* Amazonas 4,049 5,524 4,533 41.5% Eirunepe Amazonas 9,269 8,483 5,288 35.0% Itaituba Para 14,179 9,004 3,940 44.2% Rodrigues Alves Acre 3,701 3,524 4,774 38.3% Barcelos Amazonas 2,432 2,423 3,863 46.9% Sao Gabriel* Amazonas 4,049 5,524 4,533 41.5% Amazonas 5,723 4,291 3,619 49.5% Itaituba Para 14,179 9,004 3,940 44.2% Ipixuna Amazonas 4,067 5,455 2,983 51.5% Barcelos Amazonas 2,432 2,423 3,863 46.9% Macapa Amapa 1,484 4,022 2,981 53.6% Atalaia do Norte Amazonas 5,723 4,291 3,619 49.5% Tefe Amazonas 2,956 2,898 2,707 55.5% Ipixuna Amazonas 4,067 5,455 2,983 51.5% Santana Amapa 691 1,561 2,553 57.3% Macapa Amapa 1,484 4,022 2,981 53.6% Decrease 0 10,000 20,000 0 10,000 20,000Tefe 0 10,000 Am20,000azonas 02%,956 20% 402%,898 60% 2,707 55.5% Increase 2012 2013 Santana 2014Amapa 691 2014 Cumulative percenta1,g56e o1f cases 2,553 57.3%

Decrease 0 10,000 20,000 0 10,000 20,000 0 10,000 20,000 0% 20% 40% 60% Increase 2012 2013 2014 2014 Cumulative percentage of cases

*Sao Gabriel da Cachoeira - 46 - Plasmodium vivax caused 82.9% of all cases in 2014, while P. falciparum and mixed cases caused 16.3% of cases. The Figure 4. Malaria cases by age and sex in Brazil, 2014 primary vector in the Amazon area is An. darlingi. 150 Female Age groups Male Men have been more affected by malaria than women, in 50+ 118 150 2014 accounting for 60.4% of confirmed cases (Figure 45-49 years Female 105 Age groups 4). In 2014, incidence of malaria in pregnant women Male Female 100 50+ 118 40-44 years was 93 cases per 100,000 pregnant women per year, Male 97 45-49 years which was 1.75-fold higher than non-pregnant105 women 35-39 years 89 83 40-44 years of child-bearingFema age.le Throughout100 all ages, malaria 30-34 years 97 incidence was higherMale in men than in women (Figure 5). 25-29 years 35-39 years 89 In both sexes, children aged 5-9 8years3 had the highest s per 100 , 000 peop le 50 30-34 years 20-24 years s e 49 incidence among all groups. When coupled with higher C a 44 25-29 years rates of incidence in pregnant women, this suggests 15-19 years s per 100 , 000 peop le 50 20-24 years transmission occurrence in s e households. 10-14 years 22 49 150 C a 44 Female 15-19 years Age groups 5-9 years 0 Under 5-9 10-14Male15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ 10-14 years 50+ Under 5 118 22 5 yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs

45-49 years 105 0 5-9 years Figure 5. Malaria incidence by0 age and sex in Brazil, , 50 0 , 50 0 , 00 0 , 00 0 Female , 50 0 , 50 0 40-44 years 1007 5 2 2 5 7 Under 5 2014 Under 5-9 10-14 15-19 20-24 25-29 30-34 35-39 10 , 00 0 40-44 45-49 50+ 5 yrs yrs yrs yrs yrs yrMas le yrs yrs yrs97 Conyrsfirmed cases

0 35-39 years 89 83 0.53 0.40 0.51 0.36 0.22 0.71 , 50 0 , 50 0 , 00 0 150 , 00 0 Amazonas , 50 0 150 , 50 0 7 5 2 2 5 7 30-34 years Female GoldFema miningle has historically been associated with malaria Age gAroupsge groups 10 , 00 0 incidence affecting miners; however, other occupational Confirmed cases 25-29 years Male Male Acre 0.67 0.67 0.88 50+50+ 118 118 0.53 0.40 0.51 associations0.36 0 .2have2 s per 100 , 000 peop le 5 0also0.7 1 been established especially 45-49 years 105 Ama20-24zona syears s e 0.50 0.45 0.49 0.46 0.78 45-49 years 105 Amapa49 among those workingC a in timber extraction and fish 40-44 years Female 100 44 Female Acr15-19e years 0.67 0.67 0.88 40-44 years Male 97 100 farming (Figure 6). In 2014, mining cases decreasedPar a 0.54 0.41 0.53 0.42 0.76 35-39 years 89 Male 97 by 47% and loggers decreased by 19% from 2013. The 83 Amap10-14a years 0.50 0.45 0.49 0.46 0.78 22 35-3930-34 year years s 89 arrival of workers into the Amazon area has contributedRondon ia 0.60 0.38 0.59 0.37 0.85 83 5-9 years 30-3425-29 year years s Para 0.54 0.41 0.53 0.42 0 0.76

s per 100 , 000 peop le 0.76 0.23 0.75 0.23 0.29 0.55 50 to deforestation as rural areas urbanize to support thisRora ima 20-24 years s e Under4 59 Under 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+

25-29 years C a new population. Initially, deforestation was accompanied Rondonia 0.60 0.38 44 0.59 0.37 0.855 yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs 15-19 years s per 100 , 000 peop le Maranhao 0.39 0.55 0.36 0.57 0.93 50 0

s e by higher malaria incidence that flourished in chaotic 20-24 years 49 , 50 0 , 50 0 , 00 0 , 00 0 C a 10-14 years Roraima 0.76, 50 0 0.2322 0.75 40.234 , 50 0 0.29 0.55 7 5 2 2 environments,5 7 but urbanization eventually led to theMa to Grosso 0.54 0.38 0.53 0.39 0.33 0.59 15-19 year5-9 years s 10 , 00 0 0 0.39 0.55Confirmed 0ca.3s6es stabilization0.57 of physical0.9 3environments, thereby decreasing Maranhao Tocantins 0.21 0.75 0.82 0.99 10-14 yearUndser 5 Under 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ vector 2proliferation2 (24). 5 yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs Amazonas 0.53 0.40 0.51 0.36 0.22 0.71

0 Mato Grosso 0.54 0.38 0.53 0.39 0.33 0.59 5-9 years 0 Total 0.56 0.38 0.55 0.37 0.76 , 50 0 , 50 0

, 00 0 , 00 0 0.50 0.50 , 50 0 , 50 0

7 5 2 2 5 7 Acre 0.67 0.67 0.88 10 , 00 0 Under 5-9 10-14 15-19 20-20.42125-29 30-30.75 4 35-39 40-44 45-40.829 50+ 0.99 Under 5 Tocantins 0.0 0.5 1.0 0.0 0.5 1.0 0.0 0.5 1.0 Confirmed cases 5 yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs Amapa 0.50 0.45 0.49 0.46 0.78

0 *SD% **ST% Amazonas 0.53 0.40 0.51 0.36 0.2.526 00.38.71 0.55 0.37 0.76 Priority groups Total 0.50 0.50 , 50 0 , 50 0 , 00 0 , 00 0 , 50 0 , 50 0

7 5 2 2 5 Acre7 Figure 6. 0Comparative.67 analysis0.67 of malaria situation0.88 in states of the AmazonP arbasin,a 2011 0.54 0.41 0.53 <48_hour0.42 s >48_hour0s.76 No data Indigenous 10 , 00 0 0.0 0.5 1.0 0.0 0.5 1.0 0.0 0.5 1.0 Confirmed cases Plantation workers Amapa 0.50 0.45 0.49 0.46 *SD%0.78 **ST% RondonPrioriaity groups 0.60 0.38 0.59 *SD% -0.37Percentage of cases rec0e.ivi85ng a diagnosis less than or Priority Groups Amazonas 0.53 0.40 0.51 0.36 0.22 0.71 more than 48 hours after symptoms. Miners Para 0.54 0.41 0.53 0.42 0.76 **ST% -Percentage of cases receiving treatment less than or <48_hours >48_hours No data RoraIndimigenoua s 0.76 0.23 0.75 0.23 0.29 0.55 0.67 0.67 0.88 more than 48 hours after symptoms. Others RondoniaAcre 0.60 0.38 *SD0.%59 -Percen0.37tage of cases receivi0.ng85 a diagnosis less than or Plantation workers more than 48 hours after symptoms. Maranhao 0.39 0.55 0.36 0.57 0.93 Roraima 0.76 0.50.230 0.450.75 0.230.490.29 0.460.55 0.78 Miners Amapa **ST% -Percentage of cases receiving treatment less than or Mato Grosso 0.54 0.38 0.53 0.39 0.33 0.59 Maranhao 0.39 0.55 0more.36 than0.57 48 hours after symptom0.93s. Others Para 0.54 0.41 0.53 0.42 0.76 Mato Grosso 0.54 0.38 0.53 0.39 0.33 0.59 Tocantins 0.21 0.75 0.82 0.99 Rondonia 0.60 0.38 0.59 0.37 0.85 Tocantins 0.21 0.75 0.82 0.99 Total 0.56 0.38 0.55 Amazonas0.37 670.39.760 13% -33% 1,089 0.76 0.23 0.75 0.23 0.29 0.55 0.50 0.50 Roraima 0.56 0.38 0.55 0.37 0.76 Total 0.50 0.50 0.0 0.5 1.0 0.0 0Acre.5 1.0 0.0 300..5559 1.0 30% 11% 158 0.39 0.55 0.36 0.57 0.93 Maranha0.0o 0.5 1.0 0.0 0.5 1.0 0.0 0.5 1.0 *SD% **ST% Priority groups *SD% Amazonas**ST% Prior67ity.39 group0 s 13% -33% SD% and ST% 1,089 Amapa 13.535 8% -13% 148 Mato Grosso 0.54 0.38 0.53 0.39 0.33 0.59 <48_hours >48_hours No data Indigenous <48_hours >48_hours No data Indigenous Acre 30.559 30% 11% 158 Para 11.204 17% -89% 696 Plantation workers *SD% -PerTcoencantageti nofs cases rece0ivi.2ng1 a diagnosis0.75 less than or 0.82Plantation workers 0.99 *SD% -Percentage of cases receiving a diagnosis less than or more than 48 hours after symptoms. Amapa 13.53M5iners 8% -13% more than14 488 hours after symptoms. 10.206 11% -75% 323 **ST% -Percentage of cases receiving treatment less than or Rondonia Miners 0.56 0.38 0.55 0.37 0.76 **ST% -Percentage of cases receiving treatment less than or more thanT 48o thourals after symptoms. 0.50 Ot0her.50s more than 48 hours after symptoms. Others Para 11.204 17% -89% 696 Roraima 7.662 13% -49% 242 0.0 0.5 1.0 0.0 0.5 1.0 0.0 0.5 1.0 Rondonia 10.206 11% -75% 323 *SD% **ST% Priority groups Maranhao 1.395 11% -76% 248

<48_hours >48_hoursRoraimaNo data 7.662 13Ind%igenous -49% 242 Mato Grosso 879 4% -73% 133 67.390 13% -33% 1,089 Amazonas*SD% -Percentage of cases receiviMaranhaong a diagnosis le1ss.39 than5 or 11Pl%antation work-76ers% 248 Tocantins 22 14% -83% 187 more than 48 hours after symptoms. 30.559 30% 11% 158 Miners Acre Amazonas133 67.390 13% -33% 1,089 **ST% -Percentage of cases receMatoiving Grossotreatment less87 t9han or 4% -73% 0 50.000 10% 20% -50% 0% 0 500 1.000 more than13 48.53 hour5 s after symp8%toms. -13% 148 Others Amapa 30.559 30% 11% 158 Tocantins 22 14% -83% Acre 187 - 47 - P. falciparum (%) Diferencia (%) Para 11.204 17% -89% 696 Casos 2014 2014 2009-2014 Laboratorios 2011 Amapa 13.535 8% -13% 148 Rondonia 10.206 11% -75%0 50.003203 10% 20% -50% 0% 0 500 1.000 Para 11.204 17% -89% 696 Roraima 7.662 13% -49% 242 P. falciparum (%) Diferencia (%) Casos 2014 2014 2009-2014 Laboratorios 2011 Maranhao 1.395 11% -76% 248 Rondonia 10.206 11% -75% 323 Amazonas 67.390 13% -33% 1,089 Mato Grosso 879 4% -73% 133 Roraima 7.662 13% -49% 242 TocantinsAcre 22 30.55149% -83% 30% 187 11% 158 Maranhao 1.395 11% -76% 248 Amapa0 50.00013.53105 % 20% 8%-50% 0% 0 500-131.00% 0 148 Mato Grosso 879 4% -73% 133 P. falciparum (%) Diferencia (%) Para Casos 2014 11.204 2014 2009-201417% Laboratorios-89% 2011 696 Tocantins 22 14% -83% 187 Rondonia 10.206 11% -75% 323 0 50.000 10% 20% -50% 0% 0 500 1.000 Roraima 7.662 13% -49% 242 P. falciparum (%) Diferencia (%) Maranhao 1.395 11% -76% 248 Casos 2014 2014 2009-2014 Laboratorios 2011

Mato Grosso 879 4% -73% 133

Tocantins 22 14% -83% 187

0 50.000 10% 20% -50% 0% 0 500 1.000 P. falciparum (%) Diferencia (%) Casos 2014 2014 2009-2014 Laboratorios 2011 150 Female Age groups Male 50+ 118 45-49 years 105

40-44 years Female 100 Male 97 35-39 years 89 83 30-34 years 25-29 years

s per 100 , 000 peop le 50 20-24 years s e 49 C a 44 15-19 years

10-14 years 22 5-9 years 0 Under 5 Under 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ 5 yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs 0 , 50 0 , 50 0 , 00 0 , 00 0 , 50 0 , 50 0 7 5 2 2 5 7 10 , 00 0 Confirmed cases Amazonas 0.53 0.40 0.51 0.36 0.22 0.71

Acre 0.67 0.67 0.88

Amapa 0.50 0.45 0.49 0.46 0.78

Para 0.54 0.41 0.53 0.42 0.76

Rondonia 0.60 0.38 0.59 0.37 0.85

Roraima 0.76 0.23 0.75 0.23 0.29 0.55

Maranhao 0.39 0.55 0.36 0.57 0.93

Mato Grosso 0.54 0.38 0.53 0.39 0.33 0.59

Tocantins 0.21 0.75 0.82 0.99

0.56 0.38 0.55 0.37 0.76 Total 0.50 0.50 0.0 0.5 1.0 0.0 0.5 1.0 0.0 0.5 1.0 *SD% **ST% Priority groups

<48_hours >48_hours No data Indigenous

*SD% -Percentage of cases receiving a diagnosis less than or Plantation workers more than 48 hours after symptoms. Miners **ST% -Percentage of cases receiving treatment less than or more than 48 hours after symptoms. Others

Figure 7. Comparative analysis of malaria situation in states of the Amazon basin

Amazonas 67,390 13% -33% 1,089

Acre 30,559 30% 11% 158

Amapa 13,535 8% -13% 148

Para 11,204 17% -89% 696

Rondonia 10,206 11% -75% 323

Roraima 7,662 13% -49% 242

Maranhao 1,395 11% -76% 248

Mato Grosso 879 4% -73% 133

Tocantins 22 14% -83% 187

0 50,000 10% 20% -50% 0% 0 500 1,000

P. P. faliciparum falciparum (%)(%) Difference (%) Cases 2014 2014 2009-2014 Laboratories 2011

Figures 6 and 7 compare the malaria situation states plantation workers, who account for 23.7%. During of that are a part of the Amazon basin based on data 2011, in the Amazon basin indigenous populations were obtained from a report (25). Para has had the largest primarily affected in the states of Amazonas (22%) and decrease since 2009, while Acre has had an 11% Roraima (29%) (Figure 6). In Mato Grosso, miners were increase of cases. In 2011, Amazonas state had the the most affected group comprising 33% of all cases in most laboratories; however, in 2014 this state had the the state during 2011. highest number of cases. Despite having a high number of laboratories, the state only diagnosed about half of Diagnosis and Treatment their patients in less than 48 hours since the start of Microscopy3M is the main method of diagnosing malaria. In24 symptoms in 2011. In that same year, the time in which 2014, the SPR was 8.57%, but it has been on a steady the patient received treatment after diagnosis was not decline since 2010 (Figure 8). The decline in both API and illi on s) prompt. Around 36% of patients received treatment SPR further confirms the decreasing morbidity trends in SPR) 2M 16 ( m t e after more than 48 hours following diagnosis. Brazil.i n

The priority groups of concern are indigenous peoples, First-linex am i ned ( treatment for P. vivax is chloroquine and 8 who account for 15.1% of all cases in 2014, and primaquine, e 1M while artemether-lumefantrine combination Sli de Po sitivity R a P eop l e

0M 0 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 9 201 0 201 1 201 2 201 3 201 4 Figure 8. Blood slides examined, RDTs examined, FigureRDTs Ex 9.am Numberined of malariaBlood Sli decasess Exami neandd thoseSPR treated (%) and SPR in Brazil, 2000-2014 with first-line treatment in Brazil, 2000-2014

3M 24 2M

First-line treatments illi on s) SPR)

2M 16 ( m

t e Confirmed Cases i n

illi on s) 1M m i n x am i ned (

8 s ( e 1M s e Sli de Po sitivity R a f c a P eop l e

0M 0 N umber o

200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 9 201 0 201 1 201 2 201 3 201 4 0M RDTs Examined Blood Slides Examined SPR (%) 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 201 3 201 4

5M People protected by IRS First-line treatments 4M People protected by ITNs - 48 - Confirmed Cases illi on s)

m 3M illi on s) 1M i n m i n ct ed ( s ( 2M s e pro t e f c a 1M P eop l e 0M N umber o 0M 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 201 3 201 4

200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 201 3 201 4 *IRS information unavailable for 2003, 2004, and 2006.

$125M 5M People protected by IRS 4M People protected by ITNs $100M illi on s)

m 3M i n $75M illi on s) m ct ed ( 2M i n ( $50M pro t e 1M US $

P eop l e $25M 0M

$0M 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 201 3 201 4

*IRS information unavailable for 2003, 2004, and 2006. 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 201 3 201 4

Government Global Fund USAID Others $125M

$100M

$75M illi on s) m i n ( $50M US $

$25M

$0M 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 201 3 201 4

Government Global Fund USAID Others 3M 24 illi on s) SPR)

2M 16 ( m t e i n

3M 24

x am i ned ( 8 e 1M Sli de Po sitivity R a P eop l e illi on s) SPR)

2M 16 ( m t e

i n 0M 0 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 9 201 0 201 1 201 2 201 3 201 4

x am i ned ( 8 e 1M RDTs Examined Blood Slides Examined SPR (%) Sli de Po sitivity R a P eop l e

0M 0 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 9 201 0 201 1 201 2 201 3 201 4 RDTs Examined Blood Slides Examined SPRFirst (%-line) treatments Confirmed Cases

illi on s) 1M m i n s ( s e

f c a First-line treatments Confirmed Cases N umber o illi on s) 1M m 0M i n and artesunate-mefloquine are used forP. falciparum s ( Figure 10. People protected by IRS and by ITNs s e 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 201 3 201 4

infections. A 2014 study found first-line treatment f c a in Brazil, 2000-2014 failure of 5.2% in P. vivax cases and an association with high initial mean parasitemia (26). Brazil reports N umber o 5M more first-line treatment provided to people than actual 0M People protected by IRS confirmed cases; this is probably because estimates of 4M People protected by ITNs first-line treatments could be based on actual number of 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 201 3 201 4 illi on s) tablets used in a year, which is higher than actual tablets m 3M used owing to losses due to the expiration of medicines i n ct ed ( and decay of quality among other reasons (Figure 9). 5M2M People protected by IRS pro t e Vector Control 4M 1M People protected by ITNs P eop l e illi on s)

Brazil has recently reinforced efforts on distributing m 3M 0M ITNs as a method of vector control. Almost 884,000 i n 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 201 3 201 4 people were protected by ITNs in 2014, which has been ct ed ( 2M *IRS information unavailable for 2003, 2004, and 2006.

the highest estimate for Brazil thus far (Figure 10). The pro t e number of people protected has increased in the past 3 1M years, while IRS usage has decreased. At nearly 290,000 P eop l e 0M people in 2014, the number of people protected by IRS $125M

was the lowest recorded since 2007. 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 201 3 201 4 $100M *IRS inFigureformation una11.va Fundingilable for 2003 for, 2004 malaria, and 2006 in. Brazil, 2000-2014 Finances Funding for malaria has mostly come from the $75M illi on s) government and is managed in a decentralized manner. $125 m M i n In 2014, Brazil spent a little more than US$72 million ( $50M (Figure 11). The USAID has provided support to Brazil, $100US $ M particularly the Amazon area, via the AMI/RAVREDA $25M initiative since its inception in 2002. The Global Fund to $75M illi on s) $0M

Fight AIDS, Tuberculosis and Malaria has also contributed m i n to malaria control efforts and in 2009 provided a grant to ( $50M 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 201 3 201 4 make bed net usage a national policy. After 2011, Brazil US $ Government Global Fund USAID Others decided to sustain the project with domestic funds. $25M

The private sector is also obligated to contribute to malaria $0M funding if their enterprise is located in the Amazon area and their operations are found to have an impact on 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 201 3 201 4 malaria transmission. Companies must develop social Government Global Fund USAID Others responsibility programs for malaria prevention and control that follow that of the municipalities in which they are located.

- 49 -