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Report on the Situation of Malaria in the , 2000-201512

1 Document prepared by the Regional Malaria Program, Pan Health Organization with data from Annual Country Reports- 2016 General situation in endemic countries Figure 1. Malaria morbidity and mortality in the Americas, 2000 - 2015 The number of malaria cases in the of the Americas declined by 62% (1,181,095 to 451,242 cases) between 2000 and 2015 (figure 1). In 1.2M Confirmed Cases 400 the same period malaria-related deaths has declined by 61.2% (410 in 2000 to 159 deaths in 2015). An estimated 7.2 million cases and 3,200 Deaths ]

deaths were averted between 2000 and 2015, assuming that the rates s P. falciparum & mixed n 0.9M o i

from 2000 remained constant. Despite many achievements, there are l l 300 i m

still an estimated 102 million people living in areas at risk of malaria in n i [

the Americas of which, at least 28 million were living in areas s s h t considered to be at high risk (>10 cases/1,000 inhabitants). e a s 0.6M e a 200 c D

With the exception of and , most of the 21 endemic d e m

countries in the Americas have had a reduction of malaria cases till r i f

2015 compared to 2000 (figure 2). Notable changes in cases during the n o 0.3M 2010-2015 period include a decrease in Haiti and increases in , C 100 , , and Venezuela. Panama has had a 34% increase in cases during 2010-2015 with the majority of cases in the indigenous populations living in conditions of vulnerability. In Peru and Venezuela, 0.0M 0

cases have doubled and tripled, respectively during 2010-2015. The 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

areas of concern in both these countries are within the Amazon forest 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 that spans across many countries in . Peru that has had high rates of malaria in the past few years largely due In 2015, cases of malaria increased in , , to decline in access to diagnosis and treatment, and diminished vector , , , Nicaragua, Peru, and Venezuela as control interventions. In Venezuela, cases have increased annually compared to 2014. In Colombia, malaria transmission continues to be since 2008. Between 2014 and 2015, cases increased by 50% from high in the department of Choco. Cases increased during 2014 and 90,708 to 136,402. If this trend continues, Venezuela could report the 2015 and accounted for 53% of all cases in the country. The Global most cases in the Americas by 2016. The country has reported more Fund grant came to an end in 2014 and thereafter there has been a cases in 2015 than in any of the previous 50 years. The situation is decline in interventions in the state, including decreased diagnostic worsening mainly due to social and economic conditions, increased posts and vector control interventions. The Dominican Republic had a activities, and decreased vector control interventions, especially 33% increase in cases between 2014 and 2015, mostly due to a local in Sifontes municipality of the Bolivar state. outbreak in the . The increase in cases in Ecuador may be related to the reorganization of the national malaria program leading On the other hand, zero cases were reported in , , to decline in attention to case management and preventive interventions and in 2015 (table 2). Argentina has officially requested while functions were being transferred. Furthermore, case increases in WHO to initiate the process of certification of elimination. Seven other localities of the Ecuadorian may also be affected by the El countries in the Americas (, Costa Rica, Ecuador, , Nino Southern Oscillation phenomenon associated with malaria , Paraguay and ) have the potential to eliminate malaria by 2020 according to a WHO analysis presented in the report epidemics occurring every few years (figure 4). In Guatemala, 67% of “Eliminating malaria" released in 2016 (E2020). Belize reported 13 cases in 2015 were reported in the department of Escuintla where many confirmed cases, of which 4 were imported from Guatemala, Mexico people work in farms. People migrate to this area for work seasonally and Nicaragua and had 10 active foci. Six of the nine cases in El which causes reintroduction of cases in other areas within the country or Salvador were reported imported from Guatemala in 2015. Malaria neighbouring countries as workers return home following the harvest season. The Escuintla department reported the highest amount of cases transmission continues to be limited a few foci in the north of the country in the entire Mesoamerican sub-region. Honduras also had a small bordering Guatemala. Transmission in Mexico is limited to a few foci in increase of cases in 2015 due to a focal outbreak related to economic two areas of the country - southern states bordering Belize and activity (harvesting of jellyfish) on the Atlantic coast in the Moskitia area. Guatemala and in the north in Sinaloa and adjoining states. More than In 2015, the number of cases doubled in Nicaragua compared to 2014 half of the cases in Suriname have been reported imported since 2013. (from 1,163 to 2,307 cases). Cases continue to be high in the Moskitia Although , reportedly has declined malaria cases, area due to changes in economic activity increasing occupational risk, the number of cases reported imported in neighbouring countries of especially in those working on recently developed palm and cocoa Suriname (273) and (29) from that are higher than the plantations in the area. Social disturbance due to ownership has number of indigenous cases reported in French Guiana itself. been another reason for the increase. In Peru, 96% of cases in the Plasmodium vivax is the main malaria-causing species in the Americas country were reported from the state (region) of Loreto. Located in the (72% of cases in 2015). Belize, El Salvador, Mexico, and Panama , Loreto is the largest and the least populated state of report cases almost exclusively caused by P. vivax while cases in Haiti Figure 2. Decrease in malaria morbidity by countries of and the Dominican Republic are almost exclusively caused by P. the Americas, 2000 - 2015 falciparum. Plasmodium malariae is also prevalent in the Americas, though accounts for less than 0.1% of all cases. Under-diagnosis of this

100% % species is common and the prevalence could be higher. >75% Decrease 9 5

75% 3 50-75% Decrease 50% <50% Decrease Figure 3. Malaria by age group and sex, 2015 e g

n Increase 50,000 Female Male a 25% h c

e s g 0% 40,000 e a t s n a e C c -25% e d 30,000 r e P m r -50% i f

n 20,000 o

-75% C 10,000 -100% i l . r r i t y s u a a o a a e a e a a a a a i i l l i 0 p r o o z a c c z a n n n u a i i i v b a i e r m m e e d d a l i t u a a g l x r i u u a a H R 5 9 4 9 4 9 4 9 4 9 a a + e P R m m n y g a

o e -

z u B d n n v r 1 1 2 2 3 3 4 4 u 0 < . o e B e i u a l a 5 ------l B e t r r n a c t a 5 M G g a 0 5 0 5 0 5 0 5 m o

G n a s r u a o c P E . i S 1 1 2 2 3 3 4 4 o e r u o C

A S P H l N F V D C G E * Data not available for Haiti and Venezuela. Information for Guatemala and * Fr. Guiana - French Guiana, ** Dom. Rep. - Dominican Republic Nicaragua available according to age groups different from those used here. Table 1. Malaria in countries in the Region of the Americas, 2013 - 2015 Total population at Blood samples P. falciparum & Slide positivity rate Annual Parasite Country Year Confirmed Cases risk examined mixed infections (x100) Index (x1000) 2013 4,549,215 133,260 7,342 996 5.51 1.61 2014 4,549,215 124,900 7,401 341 5.93 1.63 2015 4,549,215 159,167 6,907 96 4.34 1.52 Brazil 2013 41,992,553 1,873,518 178,546 31,482 9.43 4.25 2014 35,965,912 1,658,976 143,415 23,409 8.59 3.99 2015 25,933,921 1,488,072 143,162 16,791 9.53 5.52 Colombia 2013 9,691,401 284,332 51,722 18,174 15.81 5.34 2014 10,596,997 325,713 40,768 20,504 10.10 3.85 2015 10,176,936 316,451 55,866 30,870 17.65 5.49 Dominican 2013 6,577,495 431,683 579 576 0.12 0.09 Republic 2014 4,761,804 362,304 496 491 0.14 0.10 2015 6,319,676 316,947 661 651 0.21 0.10 French 2013 199,199 22,327 877 307 3.93 4.40 Guiana 2014 125,004 14,651 448 148 3.06 3.58 2015 136,831 11,558 434 205 3.75 3.17 Guatemala 2013 6,541,912 153,731 6,214 152 4.04 0.95 2014 12,270,000 264,269 4,931 92 1.87 0.40 2015 12,600,000 295,246 5,540 51 1.88 0.44 2013 732,557 205,903 31,479 17,425 15.29 42.97 2014 747,884 142,843 12,353 5,139 8.65 16.52 2015 767,000 132,941 9,984 3,950 7.51 13.02 Haiti 2013 10,388,424 172,624 20,957 20,378 12.14 2.02 2014 10,466,500 134,766 17,696 17,696 6.77 1.69 2015 10,243,693 69,659 17,583 17,583 5.81 1.72 Honduras 2013 5,270,455 144,436 5,428 1,159 3.75 1.03 2014 5,598,244 151,420 3,380 567 2.23 0.60 2015 5,717,174 150,854 3,575 933 2.37 0.63 Nicaragua 2013 3,134,267 519,993 1,194 220 0.23 0.38 2014 3,373,499 605,357 1,163 163 0.19 0.34 2015 3,523,063 604,418 2,307 345 0.38 0.65 Panama 2013 3,724,171 93,624 705 6 0.75 0.19 2014 183,428 80,701 874 8 1.08 4.76 2015 717,489 64,511 562 6 0.87 0.78 Peru 2013 646,192 863,790 43,139 6,843 4.99 66.76 2014 11,778,357 864,413 64,676 6,988 7.48 5.49 2015 4,453,082 865,980 66,609 13,682 7.69 14.96 Venezuela 2013 5,837,393 476,764 78,643 27,659 16.50 13.47 2014 5,916,153 522,617 90,708 27,843 17.36 15.33 2015 6,165,291 625,174 136,402 35,509 21.82 22.12 Table 2. Malaria in countries of E2020 in the Region of the Americas, 2013 - 2015 Confirmed Cases Indigenous P. Imported Imported Imported Active Foci Country Year Cases Investigated falciparum P. falciparum P. vivax Argentina 2013 4 4 4 0 0 4 0 2014 4 4 4 0 0 4 0 2015 1 1 1 0 0 1 0 Belize 2013 26 26 4 0 0 4 4 2014 19 19 0 0 0 0 8 2015 13 13 4 0 0 4 11 Costa Rica 2013 6 6 4 0 1 3 0 2014 6 6 5 0 3 2 0 2015 8 8 8 0 4 4 0 Ecuador 2013 378 100 10 160 1 9 3 2014 241 2015 686 686 68 184 43 23 20 El Salvador 2013 7 7 1 0 0 1 2 2014 8 8 2 0 0 2 2 2015 9 9 6 0 0 6 4 Mexico 2013 499 499 4 0 4 0 61 2014 666 666 10 0 8 2 56 2015 551 551 34 0 6 27 50 Paraguay 2013 11 11 11 0 7 3 0 2014 8 8 8 0 7 1 0 2015 8 8 8 0 6 2 0 Suriname 2013 729 491 98 224 203 2014 401 247 2015 376 295 17 91 61 ... No data available Figure 4. Malaria by Annual Parasite Index (API) at the second administrative level (ADM-2) in the Americas - 2015Americas the- (ADM-2)in level second theadministrative at (API) Index Annual byParasite Malaria 4. Figure

Throughout the Americas, approximately 58% of all cases occurredcases all 58% of approximately Americas, the Throughout burdenin malaria high (ADM-2) with Municipalities 5. Figure in men in 2015 (figure 3). This trend has been consistent throughout beenconsistent has trend This 3). 2015(figure menin in Amazonas2015 the 2013- of countriessub-region, the years and malaria mostly affects males between the ages ofages betweenthe males affects mostly malaria and years the 15-24 years. Yet, around 9% of all cases in 2015 occurred in 2015occurred in cases all 9% aroundof Yet, years. 15-24 Municipality State Country children under 5 years of age; Brazil, Colombia, Haiti, Panama, and Haiti, Colombia, Brazil, age; of years 5 under children Sifontes Bolivar Venezuela 46,610 52,509 71,934 Peru had particularly high number of malaria cases (>10% of total (>10% casesof malaria number of high particularly hadPeru Suldo Cruzeiro Acre Brazil 20,043 17,210 14,979 cases) in children less than 5 years old suggesting that a significant a that suggesting old years 5 than less children in cases) 5,897 9,812 proportion of malaria transmission occurs within households in these in households within occurs transmission malaria of proportion Atures Amazonas Venezuela 4,377 countries. Amazonas Brazil 7,295 7,443 9,748 Gran SabanaGran Bolivar Venezuela 5,195 5,224 8,354 Amazonas SanBautista Juan Loreto Peru 7,414 10,616 8,006 The top 25 municipalities by burden of disease in the Americas the in disease of burden by municipalities 25 top The reported almost 50% of the total cases in the Region in 2015(figure in Region the in cases total the 50% of almost reported Andoas Loreto Peru 1,029 6,842 7,898 5). The majority (19) of these top 25 municipalities had an increase anhad municipalities 25 top these of (19) majority The 5). LeoniRaul Bolivar Venezuela 2,844 5,130 7,777 in malaria compared to the previous year with 13 of them reporting them of 13 with year previous the compared to malaria in Quibdo Choco Colombia 4,232 5,008 7,120 an increase of over 30% in 2015. The municipality of Sifontes in Sifontes of municipality The2015. 30% overin of increase an 5,057 5,289 6,898 Bolivar State of Venezuela alone reported approximately 16% of the16% of approximately reported Venezuelaalone of State Bolivar Cedeno Bolivar Venezuela total cases of the Region. Malaria in this municipality continues to continues municipality this in Malaria Region. the of cases total Ipixuna Amazonas Brazil 5,455 2,983 6,731 increase due to mining and social disturbances and has spread to spread hasand disturbances social and mining to due increase Eirunepe Amazonas Brazil 8,483 5,288 6,240 other neighbouring municipalities like El Callo. Shortage ofShortage Callo. El like municipalities neighbouring other Tado Choco Colombia 1,814 3,472 5,716 m edicines and declining coverage by vector control interventions control vector by coverage declining and medicines 6,207 5,552 has led to increase in other municipalities of the country, especially country, the of municipalities other in increase to led has MancioLima Acre Brazil 7,281 in the state of Amazonas. of state the in Labrea Amazonas Brazil 4,651 7,412 5,161 SaoGabriel** Amazonas Brazil 5,524 4,533 5,071 The same situation abounds in Loreto state of Peru which has led to led has which Peru of state Loreto aboundsin sameThesituation Tigre Loreto Peru 2,511 5,194 4,764 increases or very high transmission of malaria in municipalities of municipalities in malaria of transmission high very or increases that state, especially in Andoas and Tigre. Disperse populations Disperse AndoasTigre. and in especially state, that Callao El Bolivar Venezuela 340 574 4,462 living on the edges of rivers traversing the state are particularly hard particularly are state the traversing rivers edgesof the on living AlvesRodrigues Acre Brazil 3,524 4,774 4,380 to reach. There is an urgent need to sort logistical problems, logistical sort needto urgent an is There reach. to Napo Loreto Peru 859 3,207 4,344 increase access to diagnosis and treatment through community through treatment and diagnosis to access increase RamonCastilla Loreto Peru 3,911 1,851 4,341 health workers in each locality and distribution of bednets to these to bednets of distribution and locality each in workers health vulnerable populations. On the other hand, malaria has beenhas malaria hand, other On the populations. vulnerable Barcelos Amazonas Brazil 2,423 3,863 4,207 declining in many municipalities of Brazil due to the improvementin the to due Brazil of manymunicipalities in declining Nortedo Atalaia Amazonas Brazil 4,291 3,619 3,991 access to diagnosis and treatment. Noteworthy are Cruzeiro do Suldo Cruzeiro are Noteworthy treatment. and diagnosis to access Bolivar Venezuela 2,691 3,490 3,820 in Acre and Manaus in Amazonas. Municipalities of Chocoalsohave of Amazonas.Manausand Municipalities Acre in in Trompeteros Loreto Peru 1,226 2,744 3,761 reported an increase in malaria. in increase an reported 0 50,000 0 100,000 0 100,000 In In Mesoamericanhighest the with municipalities 25 the sub-region 2013 2014 2015 m alaria burden reported more than 63% of the total malaria cases in cases malaria total the 63% more thanof reported burden malaria the sub-region (figure 6). Sixteen of these reported an increase in increase an reported these of Sixteen 6). (figure sub-region the Cachoeirada SãoGabriel * m alaria cases. Malaria in La Gomera municipality of Escuintla state Escuintla of GomeraLa municipality in Malaria cases. malaria 2013-2015. during available partially were which Peru, for (ADM-3)used data District-level in Guatemala continues to increase; access to diagnosis and diagnosis to access increase; to Guatemalacontinues in Changeyearpreviousfrom treatment is particularly deficient here. Puerto Lempira in the Gracias the in Lempira Puerto here. deficient particularly is treatment Decrease Increase NoData a Dios department of Honduras is the municipality with the highest the with municipality the Hondurasis of department Dios a burdenin malaria high (ADM-2) with Municipalities 6. Figure number of malaria cases in that country. It also reported the highest the reported also It country. that in cases malaria number of Mesoamerican2015 the 2013- of sub-region, countries burden of of burden falciparum P. representing Mesoamerican sub-region the in 33.5% (434 out of 1297) of the total total the of 1297) of out 33.5%(434 falciparum P. the of cases Municipality State Country . An outbreak of malaria was reported in that in wasreported malaria of Mesoamerica.outbreak An GomeraLa Escuintla Guatemala 1,739 1,700 1,935 municipality associated with harvesting of jellyfish. El Progreso in the in Progreso El jellyfish. of harvesting with associated municipality Lempira Puerto DiosA Gracias Honduras 1,769 742 954 same country reported a 6 fold increase in malaria. in increase fold 6 a reported same country Masagua Escuintla Guatemala 580 666 807 Puerto Cabezas Puerto RACCN Nicaragua 171 179 557 Guna Yala in Panama, an archipelago, showed an increase in cases in showedincrease an Panama,archipelago, an in Guna Yala Panzos Verapaz Alta Guatemala 409 383 453 as surveillance increased with more number of health promotion health morenumber of with increased surveillance as assistants in each community. Malaria has more than doubled in doubled more than has Malaria community.each in assistants Tiquisate Escuintla Guatemala 273 223 424 Puerto Cabezas and other municipalities of RACCN Nicaraguaof in municipalities Cabezasother andPuerto Tocoa Colon Honduras 332 460 402 between 2014 and 2015 due to varied reasons. varied to between2015due2014and Waspan RACCN Nicaragua 398 305 321 Rosita RACCN Nicaragua 238 263 311 Estor El Izabal Guatemala 47 39 301 Prinzapolka RACCN Nicaragua 35 114 277 Malaria transmission was concentrated in the mostly in Grand’Anse in mostly the in wasconcentrated transmission Malaria Lucia*Santa Escuintla Guatemala 459 284 246 and Ouest department which together reported approximately 72% of approximately reported together which departmentOuest and Trujillo Colon Honduras 466 290 244 all malaria cases in Haiti. Malaria doubled in the state of Grand'Anse of state the in doubled Malaria Haiti. in cases malaria all Brus LagunaBrus DiosA Gracias Honduras 234 182 217 (figure 7). The communesThe DameRoseauxand 7). Jeremie, Marie (figure together reported 66% of the cases in the entire department. Ouest is Ouest department. entire the in cases the 66% of reported together GunaYala GunaYala Panama 156 153 200 the second department with highest number of cases althoughcases number of highest with seconddepartment the Progreso El Yoro Honduras 9 34 191 malaria is concentrated in 2 to of the 7 communes of the department:communes7 the the of of to 2 in concentrated is malaria DemocraciaLa Escuintla Guatemala 299 206 178 Croix des Bouquets and Delmas that reported almost half of all the all of half almost reported DelmasBouquetsanddesthat Croix Candelaria Campeche Mexico 0 216 174 cases in this department in 2014 and 2015. Malaria cases werecases Malaria 2015. 2014and in department this in cases Sonaguera Colon Honduras 442 217 167 diagnosed almost exclusively by passive detection in Haiti. Although Haiti. in detection passive by exclusively almost diagnosed Colon Honduras 126 179 153 surveillance in Haiti has improved over the last few years, it still it years, few last the over improved has Haiti in surveillance LagunaPerlasde RACCS Nicaragua 1 15 150 needs to be adapted to the process of elimination. Santo DomingoSanto elimination. of process the to adaptedbe needsto reported 39% and 53% of the malaria cases in 2014 and 20152014and in cases malaria 39% the 53%and reported of Morales Villeda DiosA Gracias Honduras 390 238 149 respectively of the total cases in Dominican Republic. The increase is increase The Republic. Dominican in cases total the of respectively Chepo Panama Panama 332 432 136 related to unplanned and rapidly expanding settlements in sub-urban in settlements expanding rapidly andunplanned to related Olanchito Yoro Honduras 147 86 130 areas of the capital. the of areas Chisec Verapaz Alta Guatemala 230 101 128 0 2,000 0 2,000 0 4,000 Table 3. First line of treatment for malaria by speciesby malaria for treatment of line First 3. Table 2013 2014 2015 type in the Región of the Américas the Región of the in type * Santa Lucia Cotzumalguapa, **RACCN- North Coast Autonomous**RACCN-Coast CaribbeanCotzumalguapa, North Lucia Santa * Country falciparum P. vivax P. Region , Autonomous***RACCS-Coast Caribbean SouthRegion Argentina AS+MQ;AL CQ+PQ(7) Changeyearpreviousfrom Belize CQ+PQ(1d) CQ+PQ(14) Decrease Increase Bolivia AS+MQ+PQ CQ+PQ(7) Brazil AL+PQ;AS+MQ+PQ CQ+PQ(7);CQ+PQ(14) burdenin malaria high (ADM-2) with Municipalities 7. Figure Colombia AL CQ+PQ(14) 2015 2013- Hispaniola, of Island the of countries Costa RicaCosta CQ+PQ(1d) CQ+PQ(7);CQ+PQ(14) Municipality State Country Jeremie Grand-Anse Haiti 587 465 1,801 Dominican RepublicDominican CQ+PQ(1d) CQ+PQ(14) Delmas Ouest Haiti 1,919 1,822 1,628 AL+PQ CQ+PQ(7) Ecuador Dame-Marie Grand-Anse Haiti 160 642 1,332 El Salvador CQ+PQ(14) Roseaux Grand-Anse Haiti 36 323 1,183 French GuianaFrench AQ+PGAL; CQ+PQ Croix-Des-Bouquets Ouest Haiti 1,842 1,989 1,077 Guatemala CQ+PQ(3d) CQ+PQ(14) Ansed'Hainault Grand-Anse Haiti 33 334 777 856 767 659 Guyana AL+PQ(1d) CQ+PQ(14) Port-au-Prince Ouest Haiti Arnaud Nippes Haiti 11 564 Haiti CQ+PQ(1d) CQ+PQ(14) Carrefour Ouest Haiti 1,059 1,036 542 CQ+PQ(1d) CQ+PQ(14) Honduras Corail Grand-Anse Haiti 91 113 433 Mexico CQ+PQ CQ+PQ Jacmel Sud-Est Haiti 133 249 401 Nicaragua CQ+PQ(1d) CQ+PQ(7) Anglais Les Sud Haiti 110 200 371 Panama AL+PQ CQ+PQ(7);CQ+PQ(14) Irois Les Grand-Anse Haiti 4 65 365 Paraguay AL+PQ CQ+PQ(14) Pestel Grand-Anse Haiti 17 67 336 Leogane Ouest Haiti 67 370 335 Peru AS+MQ+PQ(1d) CQ+PQ(7) Arcahaie Ouest Haiti 46 90 320 Suriname AL+PQ(1d) CQ+PQ(14) Abricots Grand-Anse Haiti 115 130 282 Venezuela AS+MQ+PQ(1d) CQ+PQ(14) Gressier Ouest Haiti 548 359 260 CQ- Chloroquine PQ- Primaquine MQ- Mefloquine AS- ArtesunateAS- MQ- Mefloquine PQ-Primaquine CQ-Chloroquine Saint-Marc Artibonite Haiti 490 320 255 AL- Artemether & Lumefantrine PG- Proguanil AQ-Atovaquone PG-Proguanil Lumefantrine & Artemether AL- Ganthier Ouest Haiti 753 502 247 For P. falciparum- (3d): 15 mg of Primaquine per day for 3 days (adults) days 3 for day per Primaquine mg15of (3d): falciparum- P. For 3 7 234 (1d): 45 mg of Primaquine in one dose on 1st day (adults) day 1st ondoseone in Primaquine mg45of (1d): Beaumont Grand-Anse Haiti For P. vivax- (14): 15 mg of Primaquine per day for 14 days (adults) days14 for day per Primaquine mg15of (14): vivax- P. For Petion-Ville Ouest Haiti 326 404 223 (7): 30 mg of Primaquine per day for 3 days (adults) days 3 for day per Primaquine mg30of (7): DomingoSanto Este DomingoSanto DOM 20 75 210 * Artemisinin-based combination therapy (ACT) is used for imported cases of P. of cases imported for used is (ACT) therapy combination Artemisinin-based * falciparum in countries using CQ as first-line treatment for this species. this for treatment CQfirst-line as using countries in falciparum Cavaillon Sud Haiti 485 250 171 Petit Goave Petit Ouest Haiti 1,336 1,164 145 0 4,000 0 4,000 0 2,000 2013 2014 2015

Data at commune level used for Haiti, DOM- RepublicDominican Haiti, for usedcommune at Data level Figure 8. Time taken for treatment since the onset of symptoms,2015 of onset 2013- the since treatment for Timetaken 8. Figure Country 2013 2014 2015 Argentina Belize Bolivia Brazil Colombia CostaRica DominicanRepublic Ecuador El Salvador El FrenchGuiana Guatemala Guyana Haiti Honduras Mexico Nicaragua Panama Paraguay Peru Suriname Venezuela

0% 25% 50% 75% 100% 0% 25% 50% 75% 100% 0% 25% 50% 75% 100% Percentage of all cases all Percentage of cases all Percentage of cases all Percentage of

Timetaken Sameday day1 days 2-3 days3 than Less days>3

Figure 9. Malaria in Vulnerable PopulationsVulnerable in Malaria 9. Figure Access to diagnosis andtreatmentdiagnosisAccess to Access to prompt diagnosis and treatment is one of the principal the of one is treatment and diagnosis prompt to Access Miners Pregnancy strategies for malaria control and elimination. This includes two includes This elimination. and control malaria for strategies components, one dependent upon the patient her/himself to seek careseek to her/himself patient dependentuponthe components,one Country Miners 2014 2015 when sick and the other being the availability of health posts with posts health of availability the being other the and whensick Argentina 0 0 diagnosis and treatment within easy access to the patient - each ofeach - patient the to accesseasy within treatment and diagnosis Belize 0 0 which requires a different intervention. different a requires which Bolivia 71 24 Advances have been seen in improving access to diagnosis to access improving Advancesin beenseenhave Brazil 95 96 (decreasing the time it takes to treat from the start of symptoms)over of start the from treat to takes it time the (decreasing Colombia 52 51 the last three years in Brazil, Colombia Dominican Republic, Mexico Republic, DominicanColombia Brazil, in years three last the and Honduras (figure 8). Data from Bolivia, Nicaragua and Peru showPeruand Nicaragua Bolivia, from Data 8). Hondurasand(figure RicaCosta 0 0 very significant improvement and needs a more detailed analysis. In analysis. moredetailed needsimprovementaand significant very RepublicDominican 2 0 some cases this is likely due to incorrect understanding of the indicator the of understanding incorrect to due likely is somethis cases Ecuador 5 (time from taking a test instead of time from start of symptoms) as wassymptoms)as of start from time of instead test a taking from (time the case in Guatemala where 2015 data reflects time taken from start from taken time reflects Guatemala 2015wheredata in case the Salvador El 0 1 of symptom but not so in 2013 and 2014.2013and in so not symptom but of GuianaFrench ...... Guatemala 0 0 Given the low number of cases in some countries very close to close very somecountries in cases number of low the Given elimination like Argentina, Paraguay, El Salvador, Belize and Costaand Belize Salvador, El Paraguay, Argentina, like elimination Guyana 1,172 849 Rica, proportions of cases diagnosed beyond 3 days seems high. This seemsdaysbeyondhigh. 3diagnosed cases of proportions Rica, Haiti 166 89 is due to a statistical anomaly and median number of days would be abe would days anomalymedianandnumber of statistical a to due is Honduras 29 47 better indicator to counter over dispersion. over counter to indicator better Mexico ... 0 Information systems in Haiti and Guyana are not adept to capture this capture to adept Guyananot and are Haiti in systems Information Nicaragua 17 23 information. In Guyana it requires updating of the health information health the of updating requires Guyana it In information. Panama 8 0 system and its adoption while in Haiti there's a need to initiate an initiate needto a there's Haiti in while adoption its andsystem Paraguay 0 0 individual case based surveillance system. basedsurveillance case individual Peru 94 134 Malaria in Vulnerable PopulationsVulnerable in Malaria Suriname 97 24 In 2015, approximately 1% of the total cases reported in the Americas the in reported cases total the 1% of approximately 2015, In Venezuela 69 145 occurred amongst pregnant women. In Haiti, pregnant women pregnant at were Haiti, women. amongst pregnantIn occurred significantly higher risk (RR=1.58, 95% C.I. 1.49-1.68) of having of 1.49-1.68) 95%(RR=1.58, C.I. risk higher significantly 0% 50% 100% 0 1,000 0 1,000 malaria than non-pregnant women in 2011-2012 (figure 9). Increase in Increase 9). women2011-2012(figure non-pregnant in than malaria Cases Total MIP* MIP* malaria incidence in Nicaragua and Honduras demonstrates anHondurasanddemonstrates Nicaragua in incidence malaria Group Others 1000pregnant per cases Malaria * improvement in quality of surveillance system while in Venezuelaand in while system surveillance of quality improvementin women Peru this implies an increase in malaria transmission and the risk. the and transmission malaria in increase an implies this Peru

Quality of surveillance system in other countries like Guatemalastill like countries other in system surveillance of Quality needsimprovement. Vector ControlVector and Spraying(IRS) ResidualIndoor byPeople protected 10. Figure Insecticide-Treated Nets (ITNs), 2000 - 2015 2000- (ITNs), Nets Insecticide-Treated There were approximately 4 million people protected by Indoorby protected people million 4 approximately wereThere 10M Residual Spraying (IRS) in the Americas in 2015 which was a decreasewasa 2015which in Americas the in (IRS) Spraying Residual IRSby protected People of 25% from 2014 (figure 10). People protected by insecticide treated insecticide by protected People 10). 25%2014(figure from of ITNsby protected People bednets (ITNs) also decreased in 2015 by 47%. There wasa47%.There2015 by in decreased also (ITNs) bednets 8M particularly notable decline in ITN coverage for 9 of 21 endemic21 of 9 for coverage ITN in decline notable particularly countries. As many as 11 countries have reported information on information reported have countries many11As as countries. insecticide resistance surveillance for for surveillance resistance insecticide Anopheles during mosquitoes 2012-2015. Almost all of these countries have reported resistance to resistance reported have countries these of all Almost 2012-2015. 6M pyrethroids in some areas except for Nicaragua, Haiti, and inand Haiti, Nicaragua, for someexcept areas in pyrethroids Suriname. 4M The majority of funding for malaria in the Americas comesAmericasfrom the in malaria for funding of majority The governmental sources (90% in 2015, figure 11). At least $16 million $16 least At 11). figure 2015, (90%in sources governmental came from external funding sources in 2015. The Global Fund Global The2015. in sources funding external came from millions] [in protected People (GFATM) alone provided $13.5 million and has supported the Americas the supported hasand million $13.5 (GFATM)provided alone 2M since 2003. Total domestic funding in countries of the Americas the of countries in funding domestic Total 2003. since increased between 2014 and 2015 by 19% (134.4 to 159.5 million) 159.5 to 19% between2015by2014and (134.4 increased despite having decreased between 2013 and 2014 (180.1 to 134.4 to between2014(180.1 decreased2013and having despite 0M million). 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Non-endemiccountries Figure 11. Financing for malaria, 2000 - 2015 2000- malaria, for Financing 11. Figure In the non-endemic countries of the Americas, a total of 1642cases of total a Americas, the of non-endemiccountries the In have so far been reported to PAHO for 2015 though this information is information this PAHO2015though to for beenreported far sohave 250M still preliminary for some countries (table 4). Approximately 2,300 Approximately 4). (table somecountries for preliminary still cases are usually reported by non-endemic countries every year. every non-endemiccountries by reported usually are cases 200M During 2013-2015, 70% of all imported cases in non-endemiccountries in cases imported all 70% 2013-2015, of During were reported to have been infected from , 8% were from ,8% fromwere Africa, from beeninfected have to reported were 5% were from the Americas, <1% from Europe and Oceania, and theand <1%Oceania,Europeand Americas, from the 5% fromwere 150M rest were of unknown origin. of were rest

In the Americas, most cases were reported imported from Guyana fromand imported reported werecases most Americas, the In 100M

Haiti (table 5). Some area wise trends can be seen. Most cases in casesMost seen. becan trends Some wise area 5). (table Haiti millions] [in US$ are imported from Peru and Brazil due to its geographical its to due Brazil andPeru from imported are Chile position. In most cases are imported from Honduras, from imported are casesmost Cayman In Islands position. 50M the Caribbean Island of the later is still endemic. Similarly imported Similarly endemic. still is later the of Island Caribbean the cases in were mostly from Venezuela and in Trinidad and Trinidad in Venezuelaand from Cubamostly were in cases Tobago they were from Guyana. Of note is that some imported casessome imported that is note Guyana.Of fromwereTobago they 0M have been reported from other non-endemic countries. Quality of Quality non-endemiccountries. other from beenreported have investigation in these cases needs a revision and sharing of sharing and revision needsa cases these in investigation 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 information is vital to ascertain if there is indeed local transmission in transmission local indeed is there if ascertain to vital is information one or the other. the or one Surinameand for 2005-11 from Haiti, for 2000-12 years the for available not Data * 2006-08 for Venezuela. Data available only for the year 2006 for French Guiana.French 2006for year the for only available Data Venezuela. for 2006-08

Bilaterals USAID UNAgencies GFATM Government BankWorld

Figure 12. Malaria by country from which cases were imported by non-endemic countries in the Region of the Americas, 2013 - 2015 Americas,2013- the Regionwhichfrom countryofcasesby thewerenon-endemic importedby Malaria in countries12. Figure

Pakistan Vietnam India Mali Haiti Chad Cambodia Panama Haiti SudanSouth Ghana French GuianaFrench Equatorial Equatorial Uganda Gabon Congo Tanzania Brazil Peru Mozambique Angola Bolivia Numbercases of 0 20 40 Import RegionImport 60 Americas 80 Asia 100 Africa 114

* Does not include cases reported imported by & of America. of States Canada byUnited & imported reported cases include Doesnot * Table 4. Number of malaria cases in non-endemic countries of the the Region of the Americas, 2000 - 2015 Americas,2000- the Region of the thenon-endemic Numberofcasesin countriesmalaria 4. Tableof Year Country 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 0 0 0 0 0 0 0 0 0 0 0 Antigua & Barbuda& Antigua 0 2 0 0 0 2 1 0 1 1 0 0 0 0 0 Bahamas 2 4 1 3 2 1 49 6 14 1 6 2 2 3 5 6 0 3 3 2 2 10 9 5 2 2 0 0 0 0 0 1 2 2 British Virgin British 0 0 0 0 0 0 0 0 0 0 0 0 Canada 438 430 347 365 375 365 333 384 372 364 514 517 477 488 447 90 CaymanIslands 3 0 3 1 1 2 1 1 1 3 0 5 Chile 7 0 5 7 7 5 3 5 4 3 5 10 6 4 8 Cuba 53 0 29 30 26 9 33 35 19 28 32 48 37 29 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 2 0 1 7 7 12 7 6 12 0 8 1 2 2 1 1 7 6 7 9 141 88 194 199 22 22 12 9 5 6 7 11 12 16 10 10 14 11 7 13 2 9 5 4 Monteserrat 0 0 0 0 0 0 0 0 0 0 0 0 Puerto 1 0 1 1 0 1 2 3 2 3 5 2 1 1 Saba 0 0 0 Saint Barthelemy Saint 0 1 Saint Kitts & Nevis& Kitts Saint 0 0 0 0 1 1 0 1 1 1 0 0 Saint 3 0 2 1 0 1 0 1 1 2 1 1 1 Saint 2 1 7 1 Saint Vincent & the G* the & Vincent Saint 0 0 0 0 0 0 0 0 1 2 0 0 Trinidad & Tobago& Trinidad 17 0 8 10 15 8 8 16 22 24 23 10 19 13 12 8 Turks & Caicos Islands Caicos& Turks 0 0 1 3 1 1 United States of America of States United 1,402 1,383 1,337 1,278 1,324 1,528 1,564 1,505 1,298 1,484 1,691 1,925 1,687 1,742 1,724 1,484 2 0 24 90 54 27 15 12 5 2 7 13 2 7 US Virgin Islands USVirgin 1 2 0 0 0 0 0 0 0 0 0 GrandTotal 1,953 1,850 1,795 1,814 1,967 2,044 2,218 2,153 1,789 1,924 2,273 2,540 2,261 2,338 2,237 1,642 *Saint Vincent & the Grenadines **Blank spaces imply no data available ***Preliminary data from Canada for 2015 Canada fromfor data ***Preliminary available data no imply spaces **Blank Grenadines the & Vincent *Saint

Table 5. Imported cases in non-endemic countries of the Americas by country / Regionof Americas / countrythenon-endemicby Imported ofcasesin countries 5. Table origin, 2013 - 2015 2013- origin,

Country / Territory Country/ Americas the of Countries 1 108 Country/Regionfrom

Chile RegionsOther Cuba U.S.A.

which malaria waswhichmalaria Islands Tobago Canada Jamaica Cayman Uruguay Grenada Bermuda Bahamas Barbados Trinidad & Trinidad Martinique

Saint Lucia Saint 1 7,576 Puerto Rico Puerto imported Guadeloupe Argentina 2 Belize 2 of States United - U.S.A. * America Bolivia 2 2 Brazil 10 2 2 18 Colombia 6 Costa RicaCosta 2 Dominican RepublicDominican 2 2 72 Ecuador 2 El Salvador El 6 French GuianaFrench 2 4 Guatemala 2 46 Guyana 12 2 6 2 40 108 Haiti 0 6 4 2 2 4 0 76 Honduras 6 2 34 Jamaica 2 Mexico 6 Nicaragua 2 4 Panama 2 2 2 Peru 4 8 72 Venezuela 12 8 4 Caribbean, unspecified Caribbean, 2 , unspecified America, Central 12 French Guiana + Guyana+Guiana French 2 South America, unspecified America, South 2 Africa 4 4 280 10 203 4 4 4 18 2 2 22 7,576 22 Asia 2 2 26 2 2 892 12 Oceania 2 32 Unknown 2 2 752 4 6 814