Overview of the situation departments coupled with constant domestic migration of the population; ii) the presence of Figures 1-5 cases of asymptomatic malaria, which go unde- Among malaria endemic countries in the Region, tected by conventional blood slide examinations; El Salvador has the lowest incidence. In 2008, the iii) the presence of the vector species and iv) country reported 33 cases of malaria, 22 of them existing malaria transmission in the rest of Cen- autochthonous and caused by Plasmodium vi- tral America, where migration between coun- vax. The remaining 11 cases were imported and, tries, including El Salvador, is frequent. of those, nine were by P. vivax, one was a case of P. vivax infection associated with an infection by P. falciparum, and another was by P. malariae. Morbidity and mortality trends Of the imported cases, eight were originally from Figures 4 – 9 Guatemala (73%), two from Honduras (18%), The number of malaria cases fell most sharply and one from Africa (9%). The growing number between 2000 and 2001 (48%) and, again, bet- of imported cases, averaging 40% of cases repor- ween 2001 and 2002 (32%). Between 2000 and ted over the last three years, highlights the need 2008, the number of cases dropped by 96%, with for intense and ongoing active surveillance. Ma- only 33 cases reported at the end of 2008. The laria incidence has declined dramatically in the decline is due, in part, to an improvement in last two decades, and reached very low transmis- surveillance activities. Deaths from malaria were sion levels by 2008, especially when compared last reported in El Salvador in 1984, and the last to the early 1980s, when the country’s burden of autochthonous case of P. falciparum malaria was disease was almost 100,000 cases. reported in 1994. Historically, the mosquito Anopheles albi- manus has been the vector species responsible Geographical distribution for malaria transmission in El Salvador. Popula- Figures 1, 12-19 tions of this species with high levels of resistance to insecticides have been described. Santiago Texacuangos was the Municipality with Although important gains have been made the largest number of autochthonous malaria ca- in recent years, there is a risk that transmission ses in 2008. It reported 11cases, or 50% of all au- will be reestablished in disease-free areas. The tochthonous cases reported in the country. San risk is a result of the following factors: i) the Francisco Menendez claimed the second highest persistence of autochthonous malaria in some number, with four cases reported in 2008, or
R e port o n t h e S i t uat i o n o f M a l ar ia i n t h e A m e r i c as , 2 0 0 8 1 3 5 1 3 6 e l S A LVADOR R e port o n t h e S i t uat i o n o f M a l ar ia i n t h e A m e r i c as , 2 0 0 8
18% of the total number of cases in the country. These are individuals in productive age, and The remaining seven cases were reported in six primarily agricultural workers (33%) and road other municipalities. construction workers (27%). Economic activity The high number of cases in Santiago Texa- was the reason for immigration in each of the cuangos resulted from an isolated malaria out- imported cases. Two of the latter cases were re- break. Six cases occurred in the municipality ported in urban areas of the municipalities of San between epidemiological weeks 4 and 5. That Salvador and San Marcos. In 2008, a case of ma- outbreak produced another five cases at the end laria associated with P. vivax and P. falciparum of the year, between weeks 46 and 52. The epi- was detected in a pregnant woman from Hon- demic behavior of malaria in this municipality duras; the case required hospitalization. A case can be attributed to: i) the area’s vulnerability to from Africa by P. malariae was also detected. climate changes; ii) the presence of asymptoma- In 2008, autochthonous cases of malaria tic cases undetected by conventional blood sli- affected mostly the population groups between de examinations; iii) geographic, environmental of 15 and 49 years of age, and were exclusively and climatic conditions favorable to propagation reported in rural areas. of the vector and iv) social and cultural factors that hamper the use of preventive and control Diagnosis and treatment measures by the population. Figures 20-24, 29–30 Economic activities are another important element in malaria transmission in Santiago In 2008, 97,872 blood slide examinations were Texacuangos. Local residents depend on tourism conducted for malaria diagnosis, yielding an an- and fishing on the shore of lake Ilopango as a nual blood examination rate (ABER) of 1%. The source of income. Tourists come both from other departments with the highest ABER and the best areas of El Salvador and from abroad. The visi- rates of surveillance were La Paz (4%), Usulutan tors are at risk of acquiring malaria in the area, (4%), Ahuachapan (3%), Chalatenango (3%) and and of carrying the infection and introducing it La Union (3%). The slide positivity rate was less into transmission-free areas. There is also a risk than 0.1%. that a new species of Plasmodium will be brought Radical treatments administered in El Salvador in by a carrier visiting from a neighboring country. consist of combined chloroprimaquine tablets, Residual transmission was responsible for i.e., chloroquine 1,500 mg and primaquine 150 the rest of the autochthonous cases in other mu- mg daily for five days. All suspected cases in 2008 had access to timely diagnosis and treatment wi- nicipalities. thin 72 hours of the onset of symptoms.
Malaria in specific populations The country’s strategy for solidifying achie- vements in malaria control includes actions Figures 25–28 that target the vector, the environment and Of all malaria cases reported in the country, 11 people. Foremost among surveillance activities (33%) were imported. Of these, 91% occurred are collective case finding, case investigation, among people between 15 and 44 years of age. the administration of presumptive combined R e port o n t h e S i t uat i o n o f M a l ar ia i n t h e A m e r i c as , 2 0 0 8 e l S A LVADOR 1 3 7
treatment in single dose schemes, and the collec- a breeding site control component and commu- tive and selective drug administration to high- nity participation. Residual spraying actions are risk populations. determined by the flow of tourists, and trends in This strategy has been recently bolstered by domestic and foreign migration. Spraying was the addition of epidemiological case surveillance also used along the country’s borders with Hon- through active and passive detection within pu- duras and Guatemala. blic health services. Surveillance today emphasi- zes timely detection and treatment of autochtho- Financing of malaria control nous cases and their contacts (due to residual Figure 34 transmission in endemic municipalities), and In 2008, the Government provided all the fun- timely detection and treatment of suspected cli- ding for malaria prevention and control activi- nical cases among travelers at border crossings, ties. Between 2005 and 2007, innovative and sus- airports and ports. Surveillance is also conduc- tainable activities were conducted with PAHO’s ted in places like mills, estates, and handmade assistance under the DDT/GEF in pilot demons- brick and tile factories, where populations at risk tration areas in the municipalities of Chalchuapa are known to seek temporary employment. in the Department of Santa Ana; Armenia, De- partment of Sonsonate; Jiquilisco, Department Prevention and vector control of Usulutan; and San Luis Talpa, San Pedro Ma- Figures 31-33 sahuat, San Luis, and La Herradura, all in the The vector of malaria in El Salvador is the mos- Department of La Paz. quito An. albimanus. Although An. pseudo- punctipennis is also present, its role as a vector of malaria has not been scientifically proven. The use of IRS as a malaria control strategy continued in 2008. It was implemented as part of a comprehensive control strategy that included 1 3 8 e l S A LVADOR R e port o n t h e S i t uat i o n o f M a l ar ia i n t h e A m e r i c as , 2 0 0 8
Figure 1. Number of cases by ADM 2 level (municipality, district), 2008
Legend
P. falciparum 1 Dot = 10 cases
Guatemala P. vivax 1 Honduras 2 3 4 5 - 11 No cases
El Salvador
Nicaragua
Figure 2. Proportion of cases by species, 2008
3%
97%
Plasmodium species P. vivax P. falciparum and mixed R e port o n t h e S i t uat i o n o f M a l ar ia i n t h e A m e r i c as , 2 0 0 8 e l S A LVADOR 1 3 9
Figure 3. Number of malaria cases by species by ADM1 level in 2008
P. falciparum + ADM1 P. vivax Total cases ADM1 mixed
San Salvador 1 13 14 San Salvador Ahuachapan 0 7 7 Ahuachapan La Union 0 4 4 La Union La Libertad 0 3 3 La Libertad Sonsonate 0 2 2 Sonsonate Usulutan 0 2 2 Usulutan Santa Ana 0 1 1 Santa Ana La paz 0 0 0 La paz
0 5 10 0% 50% 100% Plasmodium species Total number of cases Percentage of total cases P. falciparum and mixed P. vivax
Figure 4. Number of cases by species, 2000 - 2008 Figure 5. Number of malaria cases, 2000 - 2008
800 744 800 753
600 600
400 360
400 362 Number of cases 200 Number of case s 111 117 83 200 65 48
38 117
32 112
9 85 67 49
0 40 2 0 2 2 1 2 33 1 1 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year Year
Plasmodium species P. falciparum and mixed P. vivax
Figure 6. Number of malaria deaths, 2000-2008 Figure 7. Number of hospitalized malaria cases, 2000 - 2008
1
No Data Available Number of deaths
0 0 0 0 0 0 0 0 0 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year 1 4 0 e l S A LVADOR R e port o n t h e S i t uat i o n o f M a l ar ia i n t h e A m e r i c as , 2 0 0 8
Figure 8. Annual variations in number of cases Figure 9. Percentage difference in number of cases compared to 2000
2 28 1 -1 1 -1 0 0% 0% -7 -2 -1 -17 -10 -6 -34 -46 -100 ence
-200 fer -50% -52% -243 ence in number of cases centage dif
fer -300 -78% -84% Per Dif -85% -78% -78% -89% -78% -89% -89% -89% -400 -384 -91% -94% -100% -95% -96% -100% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year Year Plasmodium species P. falciparum and mixed P. vivax Plasmodium species P. falciparum and mixed P. vivax
Figure 10. Number of cases and RBM / Figure 11. Percentage of hospitalized cases, 2008 MDG targets for 2010 and 2015
No Data Available
600
400
Number of cases 200
0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Year
Reported cases RBM / MDG Targets
Figure 12. Districts (ADM2) with highest malaria burden and cummulative proportion of total cases in the country, 2008
Santiago Texacuangos 11 48% San Francisco Menendez 4 65% Conchagua 2 74% Bolivar 1 78% Ozatlan 1 83% Sacacoyo 1 87% San Juan Opico 1 91% San Salvador 1 96% Tonacatepeque 1 100% 0 2 4 6 8 10 12 0% 20% 40% 60% 80% 100% Number of cases Cummulative proportion (%) of total cases R e port o n t h e S i t uat i o n o f M a l ar ia i n t h e A m e r i c as , 2 0 0 8 e l S A LVADOR 1 4 1
Figure 13. Districts (ADM2) by number Figure 14. Districts (ADM2) by number of of malaria cases, 2008 P. falciparum cases, 2008 Number of Number of cases P. falciparum cases 11-50 1 1-5 1 1-5 8 Grand Total 1 Grand Total 9 0 1 2 3 0 2 4 6 8 10 Number of districts Number of districts
Figure 15. Districts by number of cases, API and percentage of P. falciparum cases, 2008
0 API 25 25 25 0.06 0.2 0.3 20 0.4 0.52
15
10
5
Percentage of P. falciparum cases San Francisco Menendez 0 Conchagua Santiago Texacuangos
1.5 2 3 4 5 7 10 15 20 30 40 50 70 100 150 200 300 Number of cases (logarithmic scale)
Figure 16. Annual Parasite Index (API) by districts (ADM2), 2008
Legend
Municipal API 0.01 - 1.00 1.01 - 5.00
Guatemala 5.01 - 10.00 10.01 - 50.00 Honduras 50.01 - 100.00 100.01 - 500.00
El Salvador
Nicaragua 1 4 2 e l S A LVADOR R e port o n t h e S i t uat i o n o f M a l ar ia i n t h e A m e r i c as , 2 0 0 8
Figure 17. Population by malaria Figure 18. Annual Parasite Index (API) and number transmission risk, 2008 of cases by district, 2008
Santiago Texacuangos 11 0.52 Bolivar 1 0.11 0% 10% San Francisco Menendez 4 0.08 Sacacoyo 1 0.07 Conchagua 2 0.06 Ozatlan 1 0.06 San Juan Opico 1 0.02 Tonacatepeque 1 0.01
0 5 10 0 0.2 0.4 0.6 Number of cases API 90% API (cases/ 1000 people at risk) 0 0.52
Population High risk (API > 10/1000) Medium risk (1/1000 < API < 10/1000) Low risk (API < 1/1000) Malaria free areas (No indigenous transmission)
Figure 19. Population by malaria transmission risk, 2000-08 Figure 20. Slides examined and Slide Positivity Rate (SPR). 2000-2008 Year High risk Medium risk Low risk Malaria free (API > (1/1000 < API (API < 1/1000) areas (No Year Number of slides Number of slides Slide Positivity 10/1000) < 10/1000) indigenous examined positive Rate (%) transmission) 2000 142,276 753 0.53 2000 1,350,000 907,000 3,143,000 878,000 2001 111,830 362 0.32 2001 0 2,283,000 3,179,000 889,000 2002 115,378 117 0.1 2002 0 2,641,000 3,789,000 0 2003 102,053 85 0.08 2003 0 5,000 2,714,000 3,925,000 2004 94,819 112 0.12 2004 0 5,000 2,714,000 3,925,000 2005 102,479 67 0.07 2005 0 1,273,000 318,000 745,976 2006 113,754 49 0.04 2006 4,032,000 2,234,000 725,000 1,380,366 2007 95,857 40 0.04 2007 4,032,000 2,234,000 725,000 1,380,366 2008 97,872 33 0.03 2008 0 0 705,541
Figure 21. Cases diagnosed by microscopy Figure 22. Number of cases diagnosed and RDTs, 2000-08 and cases treated, 2000-2008
Diagnostic Method Diagnosed cases Year Cases treated Year Microscopy RDTs 2000 Diagnosed cases 2000 142,276 Cases treated NA 2001 111,830 2001 Diagnosed cases 2002 115,378 Cases treated 2003 102,053 2002 Diagnosed cases 2004 94,819 Cases treated 2005 102,479 2003 Diagnosed cases 2006 113,754 Cases treated 2007 95,857 2004 Diagnosed cases Cases treated 2008 97,872 2005 Diagnosed cases 0 100,000 0 100,000 Cases treated Number of cases Number of cases 2006 Diagnosed cases Cases treated 2007 Diagnosed cases Cases treated NA 2008 Diagnosed cases Cases treated NA 0 200 400 600 Number of cases diagnosed/treated
NA- No Data Available R e port o n t h e S i t uat i o n o f M a l ar ia i n t h e A m e r i c as , 2 0 0 8 e l S A LVADOR 1 4 3
Figure 23. Slide Positivity Rate (SPR) by ADM1, 2008 Figure 24. Time span between onset of symptoms and diagnosis, 2008 ADM1 Examined Total cases SPR (%) San Salvador 3,709 14 0.38 Ahuachapan 9,488 7 0.07 0% La Union 10,485 4 0.04 La Libertad 5,342 3 0.06 Sonsonate 7,211 2 0.03 Usulutan 13,867 2 0.01 Santa Ana 9,167 1 0.01 Cabanas 1,756 0 0 Chalatenango 6,223 0 0 Cuscatlan 3,102 0 0 La paz 14,712 0 0 Morazan 1,788 0 0 100% San Miguel 7,609 0 0 San Vicente 3,413 0 0 Time span between onset of symptoms and diagnosis >72 hours <72hours
Figure 25. Number and percentage Figure 26. Number and percentage of cases by age group, 2008 of cases by locality type, 2008
<5 6.1% Urban 0.0% 5-14 6.1% Rural 100.0% 15-49 78.8% 0 10 20 >50 9.1% Number of cases 0 10 20 Number of cases
Figure 27. Number and percentage of cases in pregnant Figure 28. Number and percentage of cases women among women of child bearing age, 2008 in indegenous population, 2008
Pregnant 14.3% Amerindian 0.0% Not pregnant 85.7% Other 100.0% 0 2 4 6 0 10 20 30 Number of cases Number of cases
Figure 29. Proportion of P. falciparum cases, 2000-2008 Figure 30. Number of ACT treatments distributed by year, 2000-08 100
Not Distributed
50 falciparum cases centage of P. Per 0 0 0 0 0 0 0 0 0 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year 1 4 4 e l S A LVADOR R e port o n t h e S i t uat i o n o f M a l ar ia i n t h e A m e r i c as , 2 0 0 8
Figure 31. Indoor residual spraying Figure 32. Number of LLINs distributed by year, 2000-2008 coverage by year, 2000-08
Not Distributed 40,000 35,700 34,944 33,800 otecte d
30,000 27,560 26,520 24,923 23,540
20,000 19,387
10,000 Number of people pr 2,865 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year
Figure 33: Number of ITNs distributed by year, 2000-2008 Figure 34. Sources for malaria control funds by year, 2000-08
2,000,000
No Distribuidos 1,500,000
1,000,000 US $
500,000
0 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year
Financing sources USAID Other bilateral funds Government UN agencies Global Fund