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Cross-Border Malaria in Northern Brazil

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Cross-Border Malaria in Northern Brazil Arisco et al. Malar J (2021) 20:135 https://doi.org/10.1186/s12936-021-03668-4 Malaria Journal RESEARCH Open Access Cross-border malaria in Northern Brazil Nicholas J. Arisco1, Cassio Peterka2 and Marcia C. Castro1* Abstract Background: Cross-border malaria is a major barrier to elimination eforts. Along the Venezuela-Brazil-Guyana bor- der, intense human mobility fueled primarily by a humanitarian crisis and illegal gold mining activities has increased the occurrence of cross-border cases in Brazil. Roraima, a Brazilian state situated between Venezuela and Guyana, bears the greatest burden. This study analyses the current cross-border malaria epidemiology in Northern Brazil between the years 2007 and 2018. Methods: De-identifed data on reported malaria cases in Brazil were obtained from the Malaria Epidemiological Sur- veillance Information System for the years 2007 to 2018. Pearson’s Chi-Square test of diferences was utilized to assess diferences between characteristics of cross-border cases originating from Venezuela and Guyana, and between border and transnational cases. A logistic regression model was used to predict imported status of cases. Results: Cross-border cases from Venezuela and Guyana made up the majority of border and transnational cases since 2012, and Roraima remained the largest receiving state for cross-border cases over this period. There were sig- nifcant diferences in the profles of border and transnational cases originating from Venezuela and Guyana, including type of movement and nationality of patients. Logistic regression results demonstrated Venezuelan and Guyanese nationals, Brazilian miners, males, and individuals of working age had heightened odds of being an imported case. Furthermore, Venezuelan citizens had heightened odds of seeking care in municipalities adjacent Venezuela, rather than transnational municipalities. Conclusions: Cross-border malaria contributes to the malaria burden at the Venezuela-Guyana-Brazil border. The identifcation of distinct profles of case importation provides evidence on the need to strengthen surveillance at bor- der areas, and to deploy tailored strategies that recognize diferent mobility routes, such as the movement of refuge- seeking individuals and of Brazilians working in mining. Keywords: Cross-border malaria, Malaria elimination, Imported malaria Background across or along borders between countries sharing a land Cross-border malaria is a major barrier to elimination border (the border region can extend up through the eforts [1]. It can be of two types. First, transnational adjacent administrative areas along the international bor- malaria, defned as an internationally imported case to der, or up to a specifed distance from an international a location not within a border area (sending and receiv- border) [2]. As cross-border malaria cannot be solved ing countries may or may not be adjacent). Second, bor- unilaterally, many cross-country collaborations have der malaria, defned as an internationally imported case been established to enhance surveillance and control at borders [3, 4]. Yet, those collaborations may be difcult or impracticable when countries difer widely in their *Correspondence: [email protected] progress and commitment toward malaria elimination 1 Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 655 Huntington Avenue, Building 1, Room 1002A, when one of the countries faces civil or political unrest, Boston, MA 02115, USA and when national protocols for diagnosis, treatment, Full list of author information is available at the end of the article and control are distinct [1]. © The Author(s) 2021. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/publi cdoma in/ zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Arisco et al. Malar J (2021) 20:135 Page 2 of 13 Cross-border malaria presents many challenges, such border witnesses intense human mobility fueled pri- as the remoteness of border regions, often with limited marily by a humanitarian crisis and illegal gold mining access to health services; the varied nature of popula- activities. tion mobility (seasonal, illegal, driven by economic Roraima, a Brazilian state situated between Venezuela opportunities, or resulting from a humanitarian cri- and Guyana, bears the greatest burden among Brazilian sis); the difculty in devising surveillance systems for states [22]. Since the beginning of 2016, cross-border mobile populations; and the incomplete adherence to cases imported into Roraima have increased to nearly 500 medication that can trigger drug resistance [2]. Coun- infections per month, from less than 100 in 2015. Two tries close to malaria elimination may have the last municipalities in Roraima, namely Boa Vista (the capi- remaining cases occurring along international borders tal) and Pacaraima (bordering Venezuela), have recorded (e.g., Bhutan and India), and cross-border malaria is more than half of all cross-border malaria cases into often a threat to countries that have eliminated malaria Brazil between 2007 and 2018. Major concerns emerged (e.g., the resurgence in Costa Rica and Swaziland) [1] or among cases imported from French Guiana [20], Suri- are close to elimination (e.g., Suriname [5, 6]). name [6], Guyana [7, 12], and Venezuela [13, 23, 24]. In the Americas, malaria epidemiology has seen Tis study is a comprehensive overview of the current major changes in the past two decades. From 2000 to cross-border malaria epidemiology in Northern Brazil, 2015, malaria cases declined 61.2% in Latin America, specifcally along the Venezuela and Guyana borders, Brazil launched a Plasmodium falciparum elimination considering the years 2007 to 2018. Spatial and tempo- plan in 2015 [7], Paraguay and Argentina were certi- ral patterns in both border and transnational malaria are fed malaria-free in 2018 and 2019, respectively [8], and characterized, contrasting demographic and epidemio- El Salvador has reported zero indigenous cases since logical profles of malaria importation from Guyana and 2017 and in 2020 applied for malaria-free certifcation Venezuela. [9, 10]. However, during the same period, malaria cases increased by 359% in Venezuela and reached 411,586 in Methods 2017 (53% of the cases in the Americas) [11–13]. After Study location recording the lowest level in 36 years in 2016, malaria Brazil is divided into 5570 municipalities, and 756 cases increased by 56.9% in Brazil in 2017 and again by of those are in the Brazilian Amazon where 99.5% of 2.21% in 2018 [7]. In Guyana, malaria cases increased national malaria cases are reported. Along the Amazon 25.5% in the same period, though the total number of region, 53 Brazilian municipalities share physical borders confrmed cases annually remains under 15,000 [14]. with six malaria-endemic countries; those are denoted Tis evolving epidemiology in the Americas brought border municipalities, and comprise the border region attention to cross-border malaria along the Venezuela- (Fig. 1). Malaria cases imported from adjacent countries Brazil-Guyana border. Following political changes that to those 53 municipalities were defned as border malaria started in 2013, and an economic crisis that escalated cases. Imported cases to any municipality other than starting in 2016, Venezuela faced major challenges, the border ones, no matter the country of origin, were including in healthcare, and protests erupted. It is defned as transnational cases. Combined, they represent estimated that 4.6 million people had fed Venezuela the number of cross-border malaria cases reported in by later 2020 [15]. Te crisis also fueled an onrush of Brazil. migrants to gold mines in Bolivar State (bordering Te analysis focuses on the Venezuela-Brazil-Guyana Brazil, and where 70–80% of malaria cases are concen- border, particularly in the state of Roraima, which is trated), boosting incidence locally [13], followed by a divided into 15 municipalities, fve of which share a bor- spillover to other areas in Venezuela and across inter- der with Guyana, and fve of which share a border with national borders. Guyana, where artemisinin resistance Venezuela (Fig. 1). Te capital of Roraima, Boa Vista, had is suspected to be emerging [16], has been a hotspot a population of 375,374 people in 2018 (65.1% of the state for illegal gold-mining, and economic activity that has population). Between 2007 and 2018, 33% of all cross- been historically associated with human migration border cases in Brazil were notifed in Roraima. and malaria transmission in the Amazon. Te type of gold extraction in the region contributes to
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