Figure 1. Malaria by Annual Parasite Index (API) at VENEZUELA, BOLIVARIAN municipality level (ADM2), Venezuela 2014 REPUBLIC OF Venezuela is one of the few countries in the Americas that has had an increase of cases since 2000 and ranks as the country with the highest increase at 205% of cases. There were 90,708 cases reported in 2014, which is more than the country has reported in over 50 years (Figures 1 and 2). In the 1950s, Venezuela actually served as a model for elimination efforts and was certified by WHO to have eliminated malaria in its northern part. Despite the current alarming morbidity, Venezuela the death rates have not mirrored the morbidity trends Guyana and there has been a 79% decrease since 2000. API Malaria mostly occurs in the southern states of per 1,000 people Amazonas and Bolivar. Sifontes, a municipality in Bolivar No casesColombia state that shares a border with Guyana, has reported ≤ 0.1 0.11 - 1 1.01 - 5 5.01 - 10 ®Brazil 0 40 80 160 240 Figure 2. Number of cases and deaths due to 10.01 - 50 Kilometers Longitude/Latitude >50 Datum WGS84 malaria in Venezuela, 2000-2014 Source: PAHO/CHA/VT

100,000 50

80,000 40 10058%,000 of all cases in the country (Figure 3).50 The areas

s most affected are those where gold mining occurs. The 80,000 40 s e 60,000 30 s large population in mining areas, poor living conditions, s

s e and lack of development have all led to the increase of 60,000 30 D ea t h 40,000 20 malaria in this area. s N umber o f c a 40,000 20 D ea t h 20,000 10 In 2014, P. vivax caused 69.3% of malaria infections N umber o f c a in the country, while P. falciparum caused 23.2% of 0 0 20,cases.000 There were also 15 reported cases 1of0P. malariae 2 5 7 9 2 4 0 1 3 4 6 0 3 8 1 in 2014. Anopheles darlingi is the predominant vector in 200 200 200 200 201 201 200 200 200 200 200 201 201 200 201 0 0 2 5 7 9 2 4 0 1 3 4 6 0 3 Confirmed Cases P. falciparum & Mixed Deaths the country. 8 1 ■ P. falciparum & mixed ■ Confirmed cases ■ Deaths 200 200 200 200 201 201 200 200 200 200 200 201 201 200 201 Confirmed Cases P. falciparum & Mixed Deaths

Age groups Municipality State Figure 3. Municipalities with the highest number of malaria cases in Venezuela, 2012-2014 80+ Sifontes Bolivar 31,396 46,610 52,509 Female Age groups Municipality70-79St ayearte s Male 80+ Atures Amazonas 2,269 4,377 5,897 Sifontes 60-69Bo liyearvars 31,396 46,610 52,509 Female 70-79 years 3,604 5,057 5,289 50-59 years Male Cedeno Bolivar Atures Amazonas 2,269 4,377 5,897 60-69 years 45-49 years 2,985 5,195 5,224 50-59 years Gran Sabana Bolivar Cedeno 40-44Bo liyearvars 3,604 5,057 5,289 45-49 years Raul Leoni Bolivar 1,363 2,844 5,130 35-39 years 2,985 5,195 5,224 Gran Sabana Bolivar 40-44 years 30-34 years Sucre Bolivar 1,916 2,691 3,490 Raul Leoni Bolivar 1,363 2,844 5,130 35-39 years 25-29 years 30-34 years Piar Bolivar 2,272 2,642 2,089 Sucre 20-24Bo liyearvars 1,916 2,691 3,490 25-29 years Manapiare Amazonas 378 818 1,776 15-19 years Piar Bolivar 2,272 2,642 2,089 20-24 years 10-14 years Antonio Diaz Delta Amacuro 807 395 1,403 378 818 1,776 15-19 years Manapiare 5-9Am yearazonass 757 829 1,263 10-14 years Atabapo Amazonas Antonio Diaz DUndeltaer A 5macuro 807 395 1,403 5-9 years 10,000 5,000 0 5,000 10,000 0 80,000 0 80,000 0 Atabapo80,000 Amazonas 757 829 1,263 Under 5 Decrease Increase 2012 2013 2014 Confirmed cases 0 80,000 0 80,000 0 80,000 10,000 5,000 0 5,000 10,000 Decrease Increase 2012 2013 2014 Confirmed cases

97

97

- 98 - 100,000 50

80,000 40 s s e 60,000 30 1,000 s Female

le 856 800 Male D ea t h

40,000 20 peo p 600 N umber o f c a , 00 0 568 10 0 20,000 10 400

s pe r 241

s e 161 318 185 200

0 0 C a 2 5 7 9 2 4 0 1 3 4 6 0 3 8 1 147 0 73 200 200 200 200 201 201 200 200 200 200 200 201 201 200 201 Under 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ Confirmed Cases P. falciparum & Mixed Deaths 5 yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs Figure 4. Malaria cases by age and sex in Figure 6. Blood slides examined and SPR in Venezuela, 2014 Venezuela, 2000-2014

Age groups Municipality State 600,000 30% 80+ Sifontes Bolivar 31,396 46,610 52,509 Female 70-79 years SPR) Male d ( 2,269 4,377 5,897 e 400,000 20%

Atures Amazonas 60-69 years t e i n m

50-59 years x a Cedeno Bolivar 3,604 5,057 5,289

45-49 years l e 2,985 5,195 5,224 Gran Sabana Bolivar 1,20000,000 10% P o sitivity R a

40-44 years P eo p

Female e

1,363 2,844 5,130 35-39 years le 856 Raul Leoni Bolivar 800 Male Sli d 30-34 years peo p Sucre Bolivar 1,916 2,691 3,490 0 0% 600 0 1 2 3 4 5 6 7 8 9 0 1 2 25-29 years 3 4 , 00 0 Piar Bolivar 2,272 2,642 2,089 568 20 0 20 0 20 0 20 0 20 0 20 0 20 0 20 0 20 0 20 0 20 1 20 1 20 1 20-24 years 20 1 20 1 10 0 400 378 818 1,776 15-19 years Blood Slides Examined SPR (%) Manapiare Amazonas s pe r 241

s e 161 318 185 10-14 years 200 Antonio Diaz Delta Amacuro 807 395 1,403 C a 5-9 years 147 0 73 Atabapo Amazonas 757 829 1,263 Under 5 DiagnosisUnder and5-9 Treatment10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ 0 80,000 0 80,000 0 80,000 10,000 5,000 0 5,000 10,000 5 yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs Microscopy125,000 is used to diagnose malaria, though the Decrease Increase 2012 2013 2014 Confirmed cases Global Fund via PAMAFROFirst-line trea tdonatedments RDTs in 2007 for a

s 100,000 Confirmed Cases pilots e study conducted in the Amazon forest area (Figure 6). In75 ,2014,000 the SPR was 17.36% which, has risen in the Generally, young men between the ages of 20-24 o f c a 600,000 30% 97 years were the most affected (Figure 4). The malaria past5 0few,000 years along with the incidence rate. Medication

incidence in women (14.5 cases per 100,000) was less is N umbe r free in the public health system, but stock-outs have SPR)

d 25,000 ( beene 400, 00reported.0 A 14-day treatment of cholorquine20% t e than half of that in men (36.5 cases per 100,000 men) i n 0 andm primaquine is the first-line treatment forP. vivax

in 2014 (Figure 5). Occupation is a risk factor for men. x a 1 1 2 2 0 0 9 8 7 3 3 6 5 4 infections, while the combination4 drug of artesunate- l e 20 1 The incidence in pregnant women was 69 malaria cases 20 0 20 1 20 0 20 1 20 0 20 0 20 0 20 0 20 0 20 1 20 0 20 0 20 1 20 0 per 100,000 pregnant women in 2014, which was mefloqiune-primaquine200,000 is used forP. falciparum. 1Drug0% P o sitivity R a

*DP eo p ata for first-line treatment unavailable for 2011-2013. significantly lower than that in non-pregnant women of efficacy studies have not been reported in the past e child-bearing age (267 cases per 100,000 women for 10 years even as the probability of development of Sli d that year). This is perhaps because malaria transmission resistance0 to artemisinin remains high in the Guiana0% 8 0 2 4 0 1 3 5 7 $15M 2 4 6 9 1 3 s) 6M 60,000 Shield area. largely happensn outdoors. 20 0 20 1 20 1 20 1 20 0 20 0 20 0 20 0 20 0 20 0 20 0 20 0 20 0 20 1 20 1 illi o m

s) Blood Slides Examined SPR (%) i n n $10M Priority Groups y ITNs 4M 40,000 Figure 7. Number of malaria cases and those b illi o Gold miners are the principal population of concern d

treated m with first-line treatment in Venezuela, y IRS ( ct e i n b t e as well as those who live in populated areas near gold ( d 2000-2014

ct e $5M

mines. There is also a significant amount of indigenous US $ t e 2M 20,000 l e pr o people that are affected including the Guahibos and 125,000 P eo p Yanomamis whol e pr o reside in the Amazon area near the First-line treatments $0M

s 100,000 6 0 1 2 3 7 9 3 4 1 4 8 2 5 0 Colombian andP eo p Brazilian0M borders. 0 Confirmed Cases s e 1 1 20 0 20 0 20 0 20 0 20 0 20 1 20 1 20 0 20 0 20 0 20 0 20 0 20 1 20 1 20 1 2 2 0 0 9 7 8 3 3 6 5 4 4 75,000 o f c a 20 0 20 1 20 0 20 1 20 0 20 1 20 0 20 0 20 0 20 0 20 1 20 0 20 0 20 0 20 1 *Governmental funding data not available for 2001, 2007-2008. Figure 5. Malaria Pincidenceeople protect byed b agey IRS and sexPeo inple protected by ITNs 50G,0o0v0ernment Global Fund USAID Others N umbe r Venezuela, 2014 2598,000

0 1,000 1 1 0 2 0 2 9 3 7 8 6 5 Female 4

le 856 20 0 20 1 20 0 20 0 20 1 20 1 20 0 20 0 20 0 20 0 20 1 3 20 0 20 0 20 0 800 Male 20 1 4

peo p *Data for first-line treatment unavailable for 2011-2013. 600 , 00 0 568 10 0 400

s pe r $15M s) 6M 241 60,000 n s e 161 318 185 200 illi o C a m

147 s) i n 73 n $10M 0 y ITNs 4M 40,000 b illi o Under 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ d m y IRS (

5 yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs ct e i n b t e ( d

ct e $5M US $ t e 2M 20,000 l e pr o P eo p l e pr o 600,000 30% $0M 6 0 1 2 3 7 9 3 4 1 4 8 2 5 0 P eo p 0M 0 1 1 20 0 20 0 20 0 20 0 20 0 20 1 20 1 20 0 20 0 20 0 20 0 20 0 20 1 20 1 20 1 2 2 0 0 9 7 8 3 3 6 5 4 4 SPR) 20 0 20 1 20 0 20 1 20 0 20 1 20 0 20 0 20 0 20 0 20 1 20 0 20 0 20 0 20 1 d *Governmental funding data not available for 2001, 2007-2008.

( - 99 - e 400,000 20% t e i n People protected by IRS People protected by ITNs Government Global Fund USAID Others m

x a 98 l e

200,000 10% P o sitivity R a P eo p e Sli d

0 0% 8 0 2 4 0 1 3 5 7 2 4 6 9 1 3 20 0 20 1 20 1 20 1 20 0 20 0 20 0 20 0 20 0 20 0 20 0 20 0 20 0 20 1 20 1

Blood Slides Examined SPR (%)

125,000 First-line treatments

s 100,000 Confirmed Cases s e 75,000 o f c a 50,000 N umbe r 25,000

0 1 1 2 2 0 0 9 8 7 3 3 6 5 4 4 20 1 20 0 20 1 20 0 20 1 20 0 20 0 20 0 20 0 20 0 20 1 20 0 20 0 20 1 20 0

*Data for first-line treatment unavailable for 2011-2013.

$15M s) 6M 60,000 n illi o m s) i n n $10M 4M 40,000 y ITNs b illi o d m y IRS ( ct e i n b t e ( d

ct e $5M US $ t e 2M 20,000 l e pr o P eo p l e pr o $0M 6 0 1 2 3 7 9 3 4 1 4 8 2 5 0 P eo p 0M 0 1 1 20 0 20 0 20 0 20 0 20 0 20 1 20 1 20 0 20 0 20 0 20 0 20 0 20 1 20 1 20 1 2 2 0 0 9 7 8 3 3 6 5 4 4 20 0 20 1 20 0 20 1 20 0 20 1 20 0 20 0 20 0 20 0 20 1 20 0 20 0 20 0 20 1 *Governmental funding data not available for 2001, 2007-2008. People protected by IRS People protected by ITNs Government Global Fund USAID Others 98 1,000 Female

le 856 800 Male peo p 600 , 00 0 568 10 0 400

s pe r 241

s e 161 318 185 200 C a 147 0 73 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

600,000 30% SPR) d ( e 400,000 20% t e

1,000 i n

Female m x a le 856 800 Male l e peo p 200,000 10% P o sitivity R a 600 P eo p e , 00 0 568 Sli d 10 0 400

s pe r 241 0 0% s e 8 0 2 4 0 1 3 5 7 161 318 185 2 4 6 9 1 3 200 C a 20 0 20 1 20 1 20 1 20 0 20 0 20 0 20 0 20 0 147 20 0 20 0 20 0 20 0 20 1 20 1 0 73 Blood Slides Examined SPR (%) 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

125,000 600,000 30% First-line treatments

s 100,000 Confirmed Cases s e SPR)

d 75,000 ( e

400,000 20% o f c a t e i n

m 50,000 x a N umbe r l e 25,000 200,000 10% P o sitivity R a P eo p 0 e 1 1 2 2 0 0 9 8 7 3 3 6 5 4 4 Sli d 20 1 20 0 20 1 20 0 20 1 20 0 20 0 20 0 20 0 20 0 20 1 20 0 20 0 20 1 20 0

0 0% *Data for first-line treatment unavailable for 2011-2013. 8 0 2 4 0 1 3 5 7 Vector Control Figure 8. People 2 protected4 by6 IRS and9 by ITNs1 in3 20 0 20 1 20 1 20 1 20 0 20 0 20 0 20 0 20 0 Vector control interventions have been used extensively Venezuela, 2000-201420 0 20 0 20 0 20 0 20 1 20 1 in the past 7 years. In 2014, more than 4 million Blood Slides Examined SPR (%) $15M people were estimated to be protected by IRS (Figure s) 6M 60,000 n

8). Insecticide-treated nets have also been used as a illi o m s) i n means of vector control, but usage has been declining n $10M 4M 40,000 y ITNs b illi o

since 2008 and only protected an estimated 5,400 d m y IRS ( 125,000 ct e i n

people in 2014. b t e First-line treatments ( d

s 100,000 ct e Confirmed Cases $5M US $ s e t e 2M 20,000 l e pr o Funding 75,000 P eo p o f c a Financial resources for malaria have mostly come from l e pr o 50,000 $0M 6 0 1 2 3 7 9 3 4 1 4 8 2 5 government during the past 5 years (Figure 9). Venezuela 0 P eo p 0M 0 N umbe r 1 20 0 20 0 20 0 20 0 20 0 20 1 20 1 20 0 20 0 20 0 20 0 20 0 20 1 20 1 20 1 1 0 2 0 2 3 7 9 8 3 6 5 4 is currently not eligible for funding from the Global Fund. 25,000 4 20 0 20 1 20 0 20 0 20 1 20 1 20 0 20 0 20 0 20 0 20 1 20 0 20 0 20 0 Since 2010, governmental funding has decreased by 20 1 *Governmental funding data not available for 2001, 2007-2008. 0 People protected by IRS People protected by ITNs Government Global Fund USAID Others 1 US$11 million, though the reported decrease in funding 1 2 2 0 0 9 8 7 3 3 6 5 4 4 20 1 20 0 20 1 20 0 20 1 20 0 20 0 20 0 20 0 20 0 20 1 20 0 20 0 20 1 during 2009-2010 could be due to inconsistencies in 20 0 98 reporting. Funding increased thereafter between 2012 *FigureData for fi 9.rst- Fundingline treatme ntforun malariaavailable fo rin 2011-201 Venezuela,3. and 2014. However, the funding reported in 2014 is less 2000-2014 than that reported in 2000, while malaria incidence has reached a record high. The increase in funding reported $15M

s) 6M 60,000

during 2012-2014n is not proportional to the dramatic

increase in malariailli o cases. m s) i n n $10M 4M 40,000 y ITNs b illi o d m y IRS ( ct e i n b t e ( d

ct e $5M US $ t e 2M 20,000 l e pr o P eo p l e pr o $0M 3 4 0 1 2 3 4 5 7 8 9 2 P eo p 0M 0 1 1 20 1 20 1 20 0 20 0 20 0 20 0 20 0 20 0 20 0 6 20 0 20 0 20 0 20 1 0 20 1 20 1 2 2 0 0 9 7 8 3 3 6 5 4 4 20 0 20 1 20 0 20 1 20 0 20 1 20 0 20 0 20 0 20 0 20 1 20 0 20 0 20 0 20 1 *Governmental funding data not available for 2001, 2007-2008. People protected by IRS People protected by ITNs Government Global Fund USAID Others 98

- 100 -