10 Guatemala Overview of the situation malaria in Guatemala has affected departments in the north of the country, in other words, El Figures 1-5 Peten, Alta Verapaz, Izabal and El Quiche. But, In Guatemala, 70% of the territory is considered in recent years, transmission in the Department endemic. Although the number of cases in the of Escuintla on the Pacific coast has garnered at- country has fallen considerably in the last decade, tention. This change can be attributed to, on the transmission continues in a significant number one hand, the impact of foreign assistance on the of municipalities in over 10 departments. Of northern region of the country, where new stra- countries in Central America, Guatemala was tegies, such as ITNs, breeding site control and second only to Honduras in the number of ca- diagnostic and treatment improvements, have ses in 2008. While the number of cases by Plas- been implemented. On the other hand, mosquito modium vivax was similar in the two countries, breeding sites have proliferated in the Escuint- Guatemala had very few P. falciparum cases. It la region, as has large-scale domestic migration had only 50 cases by this type of malaria parasite driven by sugarcane harvesting activities. Mala- in 2008, all of them autochthonous. ria is present primarily in the lowlands of these Malaria in the country is focalized in three departments. areas: 1) the Pacific region, particularly in the The vector species involved are Anopheles departments of Escuintla, Suchitepequez, San albimanus, A. darlingi, A. pseudopunctipennis Marcos and Quetzaltenango; 2) northeast of and A. vestitipennis. The latter two are found in the Sierra Madre in the central-eastern zone, the region of El Peten and in Ixcan. Poor living which carries a lower burden and where Baja conditions, makeshift rural dwellings and mi- Verapaz is the most, though not the only, affec- gration in search of higher wage jobs are among ted department; and 3) in northern Guatemala, the determinants of endemic persistence in the where malaria is scattered throughout the De- country. partment of Alta Verapaz. Also part of this fo- cus are some municipalities of the departments Morbidity and mortality trends of Peten and Izabal. Figures 4 – 9 In 2008, the Escuintla Department on the Pacific coast registered 2,427 cases of malaria, the In 2000, the annual number of confirmed mala- highest number of cases in the country, followed ria cases exceeded 50,000. After a slight decrease by Alta Verapaz with 1,546 cases. Historically, in 2005, when fewer than 40,000 cases were re- RE porT O N T H E S I T UATI O N O F M A L ar IA I N T H E A M E R IC as , 2 0 0 8 1 4 5 1 4 6 GUATE ma L A RE porT O N T H E S I T UATI O N O F M A L ar IA I N T H E A M E R IC as , 2 0 0 8 ported, the country has reported a steady drop in Verapaz also had APIs of over 10 cases per 1,000 malaria transmission. Externally funded projects inhabitants. The national API was 0.9 cases per have contributed significantly to those results 1,000 people at risk, very similar to that of other since 2007. countries in the Region, such as Bolivia, Hondu- Between 2000 and 2008, the number of cases ras, and Venezuela. by P. vivax fell by 86%, and those of P. falciparum malaria, by 97%. These reductions have taken Malaria in specific populations place in the country’s northern departments Figures 25–28 and its central-eastern region, while the num- In 2008, 34% of malaria cases occurred among ber of malaria cases increased in the Pacific de- children under the age of 15 years, a percenta- partments. ge similar to that of the Region as a whole. This The number of P. falciparum malaria cases figure is much lower in other countries where dropped dramatically in 2008, and no deaths from malaria is more occupational in nature, such as malaria were reported in the country that year. in Costa Rica, Dominican Republic, El Salvador, and Guyana. Geographical distribution Most cases are of rural origin, but urban or Figures 1, 12-19 marginal urban transmission can be found in the Izabal Department, which has been undergoing In 2008, the Municipality of La Gomera repor- urbanization. In the Municipality of El Estor, ted 14.5% of the country’s cases. La Gomera was people have lived at the city limit, in an area with followed by the municipalities of Santa Cruz Ve- malaria transmission, for years. rapaz and Cotzumaguapa, with 356 cases each. Malaria in the country affects predomi- All three municipalities are in the Department nantly indigenous populations. About 65% of of Escuintla in the Pacific region. The three are malaria cases reported in 2008 occurred among followed by several municipalities with similar indigenous groups, making Guatemala one of disease situation and slight differences in the the countries in the region with the highest pro- number of reported cases. A total of 179 mu- portion of malaria cases among native peoples. nicipalities reported cases in 2008. Of these, 82 Inasmuch as 80% of the population in the nor- reported five or fewer confirmed cases, while 35 thern part of the country is of indigenous ori- reported 50 cases or more. gin, this is not surprising. Native communities The infected area in the Pacific coast region affected by malaria can be found in localities in is associated with domestic migration related to the Departments of Alta Verapaz, Quiche and sugarcane harvesting activities and to the pre- Peten, which have over the past four years been sence of artificial A. albimanus breeding sites. the target of breeding site control activities that The Municipality of La Gomera, which had the involved the local community. Case detection largest number of cases, also had the highest API among pregnant women was conspicuously low of 24.1 per 1,000 inhabitants. Four other munici- in 2008, which could be a symptom of deficien- palities in the Departments of Escuintla and Alto cies in reporting. RE porT O N T H E S I T UATI O N O F M A L ar IA I N T H E A M E R IC as , 2 0 0 8 GUATE ma L A 1 4 7 cases are treated under clinical presumption, the Diagnosis and treatment number of treatments distributed in 2008 excee- Figures 20-24, 29–30 ded the number of confirmed cases. In 2008, 170,188 blood slide examinations were Prevention and vector control conducted, yielding a 4.2% slide positivity rate. This is an important reduction vis-à-vis the pre- Figures 31-33 vious year, and the lowest SPR of the decade, The use of IRS as a vector control measure has even though the number of slides examined was declined steadily in Guatemala. Widespread in- higher than in 2007. A comparison of data by secticide use in agriculture --particularly for co- department reveals important variations in SPRs tton crops—led to vector insecticidal resistance. and case detection intensity through blood slide For the past four years, Guatemala has participa- examinations. For instance, while in Escuintla ted in the DDT/GEF project. the slide positivity rate was 18%, in Alta Verapaz A total of 12,410 people were protected by it was 5%; these two departments have the hig- indoor residual spraying in 2008, a far smaller hest number of cases. In El Peten, the SPR was number than in previous years. Various vector extremely low (0.5%). In the past two years, the control strategies with community participation network of voluntary collaborators in the North have been promoted over the past five years. Ex- has been strengthened, as has the diagnostic net- ternal funding available since 2006 has made the work, which added 40 new laboratories. implementation of LLINs possible; 700,000 of Despite significant improvements in case these have been distributed. detection, the timing of parasitological diagnosis still lags. Only 2% of all cases in 2008 had ac- Financing of malaria control cess to diagnosis within 72 hours of the onset of Figure 34 symptoms. In 2006, a project was launched with 14 million The implementation of rapid diagnostic dollars in Global Fund financing to benefit five tests has been initiated, but their use is limited health areas with intense malaria transmission in comparison to microscopy; only 2,000 ra- in northern Guatemala. In 2009, a malaria con- pid diagnostic tests were performed in 2008, as trol proposal was approved as part of the Nin- opposed to 170,000 blood slide examinations in th Round of the Global Fund, which should the same year. benefit the country’s remaining endemic areas As in the rest of the Central American su- (22 health areas). The DDT/GEF Project and bregion, P. falciparum strains circulating in Gua- Health in Action Project have also played an temala continue to be sensitive to 4- aminoqui- instrumental role in the country’s positive epi- noline; therefore, this form of malaria is treated demiological change. with chloroquine. Treatment of P. vivax malaria has been modified in recent years to extend pri- maquine administration to the classic 14-day re- commendation. Because a significant number of 1 4 8 GUATE ma L A RE porT O N T H E S I T UATI O N O F M A L ar IA I N T H E A M E R IC as , 2 0 0 8 Figure 1.