DOMINICAN REPUBLIC Figure 1

Home , Neiba, Santo Domingo Este, Santo Domingo Norte, San Gregorio de Nigua

DOMINICAN REPUBLIC Figure 1. Malaria by Annual Parasite Index (API) at The Dominican Republic has reduced malaria by 59.8% municipality level (ADM2), Dominican Republic since the year 2000. Though the WHA 58.2 target for 2014 MDG 6C may not be reached by 2015, the country has achieved a notable decrease in morbidity (Figures 1 API and 2). In 2014, the Dominican Republic was classified per 1,000 people as being in the pre-elimination phase. In 2010, the No cases ≤ 0.1 country had a surge of cases after the earthquake struck 0.11 - 1 neighboring Haiti. Since then, morbidity has decreased Haiti 1.01 - 5 by 80%. 5.01 - 10 Dominican Republic 10.01 - 50 >50 Figure 2. Number of cases and deaths due to malaria in Dominican Republic, 2000-2014 ® 0 25 50 100 Kilometers Longitude/Latitude 4,000 20 Datum WGS84 Source: PAHO/CHA/VT

3,000 15 s s e s f c a 2,000 10 D ea t h Dajabon is known for its binational market attracting N umber o 1,000 4,000 5 many Haitians 20and Dominicans alike, leading to movement of people across the border. Approximately 0 0 2000 Haitians are allowed to enter the country twice 3,000 weekly to buy and15 sell goods since 2005 when the s 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 market was established. Malaria is attributed to this Conﬁrmed Cases s e P. falciparum & Mixed Deaths s

■ P. falciparum &f c a mixed ■ Confirmed cases ■ Deaths immigration in Dajabon, but cases have decreased in 2,000 the past year (1710 cases compared to 1000 in 2007) due to focused interventions,D ea t h improvements in

N umber o surveillance, and partner support. Municipality Province 1,000 5 Santo Domingo Norte Santo Domingo 5 10 110 Santo Domingo EsteTheS anprovincesto Domingo of13 Santo Domingo20 had an outbreak75 in The country investigates all cases and found that 37 13 10 45 Tamayo Baoruco 0 0 Neiba 2014,Baoru reportingco 16117 more cases23 from 2013 particularly43 cases were imported in 2014. During 2012-2014, 0 1 3 5 4 6 7 9 2 8 1 4 0 2 Las Yayas de Viajamina theAzu a municipalities6 of Santo0 Domingo North33 and there was 3 70 municipalities designated as stratum 2 Higuey La Altagracia 7 30 28 200 200 200 200 201 201 200 200 200 200 201 201 Santo Domingo East (Figure 3). In200 the northwestern 200 and 71 as201 stratum 1 (Figure 4). However, there were Cristobal Independencia 1 8 22 Santo Domingo* part Distofr itothe Naci onacountry,l 4 theConﬁ rmedmunicipality3 Cases of Dajabon18 P. falci parumhas & Mixed 14 municipalitiesDeaths with more than 1 case per 1,000 Dajabon decreasedDajabon its cases considerably99 51 in the past17 decade. inhabitants in 1 or more years (stratum 3). San Gregorio** San Cristobal 0 0 12

Decrease 0 50 100 0 50 100 150 0 50 100 Figure 3. Municipalities2012 with the 201highest3 number2014 of malaria cases in Dominican Republic, 2012-2014 Increase Municipality Province *Santo Domingo de Guzman **San Gregorio de Nigua Santo Domingo Norte Santo Domingo 5 10 110 Santo Domingo Este Santo Domingo 13 20 75 Tamayo Baoruco 13 10 45 Stratum 1 71 Stratum 2 Neiba Baoruco 17 70 23 43 Stratum 3 Las Yaya1s4 de Viajama Azua 6 0 33 0 Higue10 y 20 30 La Alt4agra0 cia 50 7 60 70 30 28 Number of municipalities Cristobal Independencia 1 8 22 *Stratum 1: No autochthonous malaria case in 2012-2014; Stratum 2: <1 case perS 1000anto inhab Domitaningots in *2012-2014; Distrito Nacional 4 3 18 Stratum 3: >1 case perD 1000ajabo inhabn itants in ≥1 year. Dajabon 99 51 17 San Gregorio** San Cristobal 0 0 12

Decrease 0 50 100 0 50 100 150 0 50 100 2012 2013 2014 Increase *Santo Domingo de Guzman **San Gregorio de Nigua

Stratum 1 71 Stratum 2 70 Stratum 3 14 - 56 - 0 10 20 30 40 50 60 70 Number of municipalities *Stratum 1: No autochthonous malaria case in 2012-2014; Stratum 2: <1 case per 1000 inhabitants in 2012-2014; Stratum 3: >1 case per 1000 inhabitants in ≥1 year. Figure 4. Number of municipalities (ADM2) by strata in an incidence of 3.7 cases per 100,000 women. Men Dominican Republic, 2012-2014. between the ages of 20-24 had the highest incidence in 2014 (Figure 6). Stratum 1 71 Diagnosis and Treatment Stratum 2 70 Rapid diagnostic tests to detect malaria have been introduced in the past 5 years; however, microscopy Stratum 3 14 has been the primary method used to diagnose malaria (Figure 7). Around 80% of suspected cases were tested 0 20 40 60 80 through active case detection and 43% of all confirmed Number of municipalities cases in the country were confirmed through active *Stratum 1: No autochthonous malaria case in 2012-2014; surveillance. Age groups Stratum 2: < 1 case per 1000 inhabitants in 2012-2014; Stratum 3: > 1 case per 1000 inhabitants in ≥1 year. 50+ Chloroquine and primaquine is the first-line treatment 45-49 years for both P. falciparum and P. vivax infections. Studies Female on Hispaniola Island have shown that P. falciparum 40-44 years Male Anopheles albimanus is the principal malaria vector 35-39 years present on the Island in both the Dominican Republic continues to remain sensitive to chloroquine. Haiti and Haiti. All malaria cases are caused by P. falciparum, follows the same treatment regimen. 30-34 years though the country reported 5 P. vivax cases in 2014, 25-29 years Time from onset of symptoms to treatment has gradually all imported from Venezuela. Haiti, on the other hand, 20-24 years exclusively reported P. falciparum cases. worsened since 2012. Currently about 79% of patients receive treatment after more than 72 hours after onset 15-19 years 10-14 years Men in general tend to be more at risk of malaria in of symptoms (Figure 9). Many cases are reported in the Dominican Republic and accounted for 60.9% of Haitians, some of whom do not go to a health center 5-9 years all cases in 2014 (Figure 5). The incidence in men was when they are sick owing to their illegal immigration Under 5 status in the country. 5.8 cases per 100,000 men in 2014, while women had 50 25 0 25 50 Conﬁrmed cases Figure 6. Malaria incidence by age and sex in Figure 5. Malaria cases by age and sex in Dominican Republic, 2014 Dominican Republic, 2014 600,000 100% 10 Female Age groups 10 9 Male 50+ 450,000 75% 8

45-49 years SPR) (

6 t e 40-44 years Female 6 x am i ne d 300,000 50% Male 5 e 35-39 years

4 sitivity R a

4 P eop l e

30-34 years s per 100 , 000 peop le 150,000 25% s e Sli de P o

25-29 years C a 2 2 20-24 years 1 0 0% 0 1 6 9 2 4 5 7 8 3 1 2 0 3 0 1 4 15-19 years 200 200 200 200 201 201 200 200 200 200 200 201 201 Under 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ 200 201 10-14 years 5 yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs RDTs Examined Blood Slides Examined SPR (%)

5-9 years

Under 5

50 25 0 25 50 Conﬁrmed cases 4,000 100% First-line treatments Conﬁrmed Cases 3,000 75%

s 63% s

s e 73%

s e 79% f c a 10 600,000 100% f c a 2,000 50% 10 Female 9 Male

450,000 75% N umber o P er c en t age o 23% 8 1,000 25% 10% SPR) 8% (

6 t e 10% 10% 7% 0% 6 x am i ne d 300,000 50% 0 e 4 7 0 8 1 9 2 3 5 6 0 1 2 3 5 4 2012 2013 2014

4 sitivity R a 200 200 200 200 201 200 200 201 201 200 200 200 201 200 201

4 P eop l e >72 hours 48-72 hours 24-48 hours <24 hours s per 100 , 000 peop le 150,000 25% s e Sli de P o C a 2 2 1 0 0% - 57 - 0 1 6 9 2 4 5 7 8 3 1 2 0 3 0 1 4 200 200 200 200 201 201 200 200 200 200 200 201 201 Under 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ 200 201 5 yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs RDTs Examined Blood Slides Examined SPR (%)

4,000 100% First-line treatments Conﬁrmed Cases 3,000 75%

s 63% s

s e 73% s e 79% f c a f c a 2,000 50% N umber o

P er c en t age o 23% 1,000 25% 10% 8% 10% 10% 7% 0 0% 4 7 0 8 1 9 2 3 5 6 0 1 2 3 4 2012 2013 2014 200 200 200 200 201 200 200 201 201 200 200 200 201 200 201 >72 hours 48-72 hours 24-48 hours <24 hours Age groups 50+

45-49 years

40-44 years Female Male 35-39 years

30-34 years

25-29 years

20-24 years

15-19 years

10-14 years

5-9 years

Under 5

50 25 0 25 50 Conﬁrmed cases

Age groups 50+

45-49 years 600,000 100% 10 Female 10 40-44 years Female 9 Male Male 35-39 years 450,000 75% 8

30-34 years SPR) (

6 t e 25-29 years

6 x am i ne d 300,000 50% 20-24 years 5 e

4 sitivity R a 15-19 years 4 P eop l e

s per 100 , 000 peop le 150,000 25%

s e 10-14 years Sli de P o C a 2 5-9 years 2 1 0 0% Under 5 0 1 6 9 2 4 5 7 8 3 1 2 0 3 0 1 4 200 200 200 200 201 201 200 200 200 200 200 201 201 Under 5-9 10-150 4 15-192520-24 25-209 30-34 35-3259 40-44 45-450 9 50+ 200 201 5 yrs yrs yrs yrsConﬁyrrmeds casyress yrs yrs yrs yrs RDTs Examined Blood Slides Examined SPR (%) Figure 7. Blood slides examined, RDTs examined, Figure 9. Time between first symptom and and SPR in Dominican Republic, 2000-2014 initiation of treatment in Dominican Republic, 2012 - 2014

10 600,000 100% 10 Female 9 4,000 100% Male First-line treatments 450,000 75% 8 Conﬁrmed Cases SPR) 3,000 ( 75% 6 t e s 63% s s e

6 x am i ne d 300,000 50% 73% s e 79% e

5 f c a f c a 4 2,000 sitivity R a 50%

4 P eop l e s per 100 , 000 peop le 150,000 25% s e Sli de P o N umber o C a

P er c en t age o 23% 2 2 1,000 25% 10% 1 0 0% 8% Age groups 0 1 10% 10% 7%

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 0%50+ Under 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ 0 4 7 0 8 1 9 2 3 5 6 0 1 2 3 5 yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs RDTs Examined Blood Slides Examined SPR (%) 4 45-49 years 2012 2013 2014 200 200 200 200 201 200 200 201 201 200 200 200 201 200 201 40-44> 72year hours s 48-72 hours 24-48 hourFsemale <24 hours Male 35-39 years

30-34 years

4,000 Vector100% Control 25-29 years First-line treatments Figure 10. People protected by IRS and by ITNs in Both IRS and ITNs are used as a means of vector control. 20-24 years Conﬁrmed Cases The amount of people protected by IRS and ITNs has Dominican Republic, 2000-2014 3,000 75% 15-19 years

s 63%

s decreased in 2014 by 87.8% and 41.4% in 2013 (Figure

s e 73% 10-14 years s e 10). This is due, in part, to the decrease in79% malaria 300,000 f c a f c a 5-9 years People protected by IRS 2,000 incidence50% in areas of high endemicity. Resistance to 250,000 People protected by ITNs Under 5 organophosphate insecticides in Dajabon was confirmed 300,000

N umber o 200,000 People protected by IRS d

inP er c en t age o 2012 in An. albimanus, but tests yielded possible 50 25 0 25 50 1,000 25% 23% 250,000 10% ct e People protectCeond bﬁyrmed ITNs cases resistance in 2014. Confirmed resistance to pyrethroids8% t e 10% 150,000 10% 7% pr o

was found in 3 provinces in 2013 (El Seibo and La l e 200,000 0% d

0 op

Altagracia in the east and Montecristi in the northwest). ct e 4 7 0 8 1 9 2 3 5 6 100,000 P e 0 1 2 3 4 2012 2013 2014 t e 150,000 200 200 200 200 201 200 200 201 201 200 200 200 201 200 201 pr o

>72 hours 48-72 hours 24-48 hours <24 hours 600,000l e 50,000 100% Funding 10 Female op 10 100,000 P e The government has consistently provided9 fundsMale for 0 0 1 2 3 4 5 6 7 8 9 0 1 2 3 450,000 75% 4 0 0 0 0 0 0 0 0 0 0 1 1 1 1 malaria (Figure 11). The Global Fund has been the main 1 8 50,000 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 SPR)

external source for malaria funds since 2009. However, ( after the 2014 grant came to an end, the country6 is no *Data for IRS0 unavailable for 2000. t e 1 0 2 3 5 7 8 4 9 6 0 1 2 3 4

6 x am i ne d 300,000 50% 0 0 0 0 1 0 0 0 0 0 0 1 1 1 1 e 2 0 2 0 2 0 2 0 2 0 longer eligible for new financing. Additional funding5 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 has also been provided by4 USAID in the past, yet new sitivity R a 4 P eop l e *Data for IRS unavailable for 2000. initiativess per 100 , 000 peop le such as EMMIE and Malaria Zero will provide 150,00Figure0 11. Funding for malaria in Dominican25% Republic,

s e $8.0M Sli de P o

externalC a support in the future for malaria elimination in 2 2 2000-2014 Hispaniola.1 0 0% 0 1 6 9 2 4 5 7 8 3 1 2 0 3 $6.0M 4 0 1 $8.0M 200 200 200 200 201 201 200 200 200 200 200 201 201 Under 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ 200 201 s) Figure5 8. Numberyrs yrs ofyrs malariayrs yr casess yrs andyrs thoseyrs yrs yrs RDTs Examined Blood Slides Examined SPR (%) illi on $4$6..0M m

treated with first-line treatment in Dominican i n (

Republic, 2000-2014 s) US $ illi on $4.0M m $2.0M i n 4,000 100% (

First-line treatments US $ Conﬁrmed Cases $0$2.0M 1 5 8 9 2 6 7 0 4 3 1 3 4 3,000 75% 0 2 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1

s 63% 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 s

s e 73%

s e 79%

f c a $0G.o0vMernment Global Fund USAID Others f c a 50%

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

N umber o Government Global Fund USAID Others P er c en t age o 23% 1,000 25% 10% 8% 10% 10% 7% 0 0% 2012 2013 2014 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 >72 hours 48-72 hours 24-48 hours <24 hours

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