COSTA RICA Figure 1

Home , La Cruz (canton), Nandayure (canton)

COSTA RICA Figure 1. Malaria in Costa Rica by foci, 2014 Costa Rica has met the WHA 58.2 target for MDG 6C

and reported only 6 malaria cases in 2014, a 99.7% Nicaragua decrease since 2000 (Figures 1 and 2). The country is currently in the elimination phase and has reported less than 10 cases since 2012. There have been no deaths reported since 2009. )"

Cases are dispersed throughout the country and all cases except one were imported in 2014 (Table 1 and Figure Costa(! Rica 3). Three P. falciparum cases were imported from Africa and two P. vivax cases were imported from Nicaragua. One case of recrudescence of P. malariae was also Foci D Cleared up reported. The provinces of Huetar Atlantica and Huetar !( Endemic # Norte have transformed since 2000 due to agricultural * New Potential ") New active developments, particularly in banana and citrus farms. !( Pseudofocus # Panama The transformation has led to an increased risk of * Residual active ") Residual non-active Figure 2. Number of cases and deaths due to ® malaria in Costa Rica, 2000-2014 0 25 50 100 Kilometers Longitude/Latitude Datum WGS84 3,750 3 Source: PAHO/CHA/VT

malaria due to vector habitat changes and an increase in Cases Impor Cases Impor Cases Impor

s 2,500 2 human migration to work in these areas. Most cantons Districts State 12 ted 12 13 ted 13 14 ted 14 s e

s of Costa Rica have not reported local transmission in f c a t h a o Desamparados San Jose 1 1 r the last 3 or more years (stratum 1) (Figure 4). The last D e

Guacimo Limon 0 0 1 1 mb e autochthonous case of malaria was reported in the 1,250 1 N u Nandayure Guanacaste 0 0 1 1 canton of Puntarenas in 2013. This is the only malaria endemic area of the country in recent years. Strangely, Sarapiqui Heredia 0 1 0 a few autochthonous cases of P. malariae have been Siquirres Limon 0 0 1 1 0 0 reported during 2012-2014, although records indicate 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 0 0 0 0 0 0 0 0 0 0 1 1 1 1 San Carlos Alajuela 1 0 1 0 1 1 1 no transmission since 1962. 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 3 0 2 1 Puntarenas Puntarenas Conﬁrmed Cases P. falciparum & Mixed Deaths ■ P. falciparum & mixed ■ Confirmed cases ■ Deaths La Cruz Guanacaste 0 1 1 Anopheles albimanus and An. pseudopunctipennis are the primary malaria vectors. Upala Alajuela 0 1 1

Carrillo Guanacaste 1 1 0

Golﬁto Puntarenas 1 0 0 Table 1. Cantons with malaria in CostaImpor tRica,ed Case s2012-2014

San Jose San Jose 1 0 100 Autochthonous Cases

Talamanca Limon 1 0 0 Canton Province 2012 2013 2014 Total cases Imported cases Total cases Imported cases Total cases Imported cases

s 75 s e Desamparados San Jose 0 0 0 0 1 1 f c a

o Guacimo Limon 0 0 0 0 1 1 50 Stratum 1 75 m be r Nandayure Guanacaste 0 0 0 0 1 1 N u Sarapiqui Heredia 0 0 0 0 1 0 6 Stratum 2 Siquirres25 Limon 0 0 0 0 1 1 San Carlos Alajuela 1 0 1 0 1 1 0 20 40 60 80 Number of cantons Puntarenas0 Puntarenas 3 0 2 1 0 0 *Stratum 1: No autochthonous malaria case in 2012-2014; La Cruz2 010 Guanacaste2011 2012 20013 20140 1 1 0 0 Stratum 2: <1 case per 1000 inhabitants in 2012-2014; 0 0 1 1 0 0 Stratum 3: >1 case per 1000 inhabitants in ≥1 year Upala Alajuela Carrillo Guanacaste 1 1 0 0 0 0 Golfito Puntarenas 1 0 0 0 0 0 San Jose San Jose 1 0 0 0 0 0 Talamanca Limon 1 0 0 0 0 0

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Cases Impor Cases Impor Cases Impor

s 2,500 2 Districts State 12 ted 12 13 ted 13 14 ted 14 s e s f c a t h a o

Desamparados San Jose 1 1 r D e

Guacimo Limon 0 0 1 1 mb e 1,250 1 N u Nandayure Guanacaste 0 0 1 1 3,750 3 Sarapiqui Heredia 0 1 0

Siquirres Limon 0 0 1 1 0 0 2 3 7 1 4 5 8 9 6 0 1 3 4 0 2 0 0 0 1 0 0 0 0 0 1 1 1 Cases Impor Cases Impor Cases Impor San Carlos Alajuela 1 0 1 0 1 1 0 0 1

s 2,500 2 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 Districts State 12 ted 12 13 ted 13 14 ted 14 2 0 2 0 2 0 s e

s Puntarenas Puntarenas 3 0 2 1 f c a

t h Conﬁrmed Cases P. falciparum & Mixed Deaths a o

Desamparados San Jose 1 1 r

D e La Cruz Guanacaste 0 1 1

Guacimo Limon 0 0 1 1 mb e 1,250 1 N u Upala Alajuela 0 1 1 Nandayure Guanacaste 0 0 1 1 Carrillo Guanacaste 1 1 0 Sarapiqui Heredia 0 1 0 Golﬁto Puntarenas 1 0 0 Imported Cases Siquirres Limon 0 0 1 1 0 0 2 3 7 1 4 5 8 9 6 0 1 3 4 0 2 100 Autochthonous Cases 0 0 0 1 0 0 0 0 0 1 1 1 San Carlos Alajuela 1 0 1 0 1 1 0 0 1 San Jose San Jose 1 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 2 0 3 0 2 1 Talamanca Limon 1 0 0 Puntarenas Puntarenas FigureCon ﬁ3.rme Autochthonousd Cases P. falci andparum imported & Mixed casesDeaths in Figure 4. Number of cantons by strata in La Cruz Guanacaste 0 1 1 s 75

Costa Rica, 2010-2014 Costa Rica, 2012-2014 s e Upala Alajuela 0 1 1 f c a Carrillo Guanacaste 1 1 0 o 50 Golﬁto Puntarenas 1 0 0 Imported Cases Stratum 1 75 m be r N u San Jose San Jose 1 0 100 Autochthonous Cases 6 Talamanca Limon 1 0 0 Stratum 2 25

s 75

s e 0 20 40 60 80 Number of cantons f c a 0 o *Stratum 1: No autochthonous malaria case in 2012-2014; 2010 2011 2012 2013 2014 50 Stratum 1 75 m be r Stratum 2: <1 case per 1000 inhabitants in 2012-2014; N u Stratum 3: >1 case per 1000 inhabitants in ≥1 year Age groups 6 Stratum 2 25 50+ 45-49 years 0 20 40 60 80 Despite the small amount of cases in the past 3 years, 40-44 years Number of cantons 0 access toAg diagnosise groups and treatment is estimated to be *Stratum 1: No autochthonous malaria case in 2012-2014; 2010 2011 2012 2013 2014 relatively quick,35-39 50owingyear+s to the unique model of health Stratum 2: <1 case per 1000 inhabitants in 2012-2014; 45-4930-34 year years s Stratum 3: >1 case per 1000 inhabitants in ≥1 year system in Costa Rica (Figure 8). Apart from the hospitals 40-4425-29 year years s and clinics, basic20-24 year teamss for comprehensive healthcare provide last-mile35-39 year s connectivity, increasing access to 30-3415-19 year years s Diagnosis and Treatment healthcare through periodic home visits. Cases of P. 25-2910-14 year years s Fewer blood slides have been examined due to the Female falciparum20-24 imported5-9 year years s from countries with documented Male decrease in cases over the years, amounting to about chloroquine resistanceUnder 5 are treated with ACT. 4,500 slides in 2014 (Figure 6). The country has recently 15-19 years 10-14 years 4 2 0 2 4 been in the process of transitioning microscopic staining Female Figure 6. Blood5-9 year slidess examinedCon andﬁrmed SPR cases in techniques from modified Romanowsky to Giemsa. Male Costa Rica, 2000-2014Under 5 Chloroquine and primaquine are used as first-line 4 2 0 2 4 treatment for both P. falciparum and P. vivax infections. Conﬁrmed cases 60,000 30% SPR) Figure 5. Malaria cases by age and sex in 40,000 20% ( 30% t e Costa Rica, 2012-2014 60,000

Age groups 10% sitivity R a

20,000 SPR) 50+ 40,000 20% ( t e Bl ood Sli de s Ex am i ne d 45-49 years Sli de P o 40-44 years 0 0% sitivity R a 35-39 years 20,000 10% 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

30-34 years Bl ood Sli de s Ex am i ne d Blood Slides Examined SPR (%) Sli de P o 25-29 years 0 0% 0 1 2 3 4 5 6 7 9 20-24 years 8 1 0 4 2 3 201 200 201 201 200 200 200 200 200 200 200 200 15-19 years 200 201 201

10-14 years FigureBlood Sli 7.de sNumber Examined of malariaSPR (%) cases and those Female 5-9 years treated with first-line treatment in Costa Rica, Male 50,000 First-line treatments Under 5 2000-2014 Conﬁrmed Cases 4 2 0 2 4 s Conﬁrmed cases s e f c a 25,000 50,000 First-line treatments

N umber o Conﬁrmed Cases s

60,000 30% s e

f c a 0 3 2 4 5 8 0 1 6 7 9 1 2 25,000 0 3 4 200 200 200 200 200 201 201 200 200 200 200 200 201 201 201 SPR) N umber o 40,000 20% ( t e

100% sitivity R a 50,000 10% 20,000 200 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

Bl ood Sli de s Ex am i ne d 40,000 80% Sli de P o d s 0 0% ct e 30,000 s e 0 1 2 3 4 5 6 7 9 8 1 0 4 60% 2 3 f c a 100% 50 pro t e ,000 201 200 201 201 200 200 200 200 200 200 200 200 100% 200 100% 201 100201 % 100% 100% 20,000

40P eop l e ,000 Blood Slides Exam80ine%d 40% SPR (%) 10,000 d P er c en t age o

- 54 - s ct e 30,000

s e 20% 0 60% 1 f c a 2 0 9 7 8 3 6 5 1 4 pro t e 2 0 3 4 100% 100% 100% 100% 100% 20,000 200 201 201 200 200 201 200 200 200 200 201 200 200 200 0% 201

40% 2010 2011 2012 2013 2014 P eop l e 10,00Peop0 le protected by IRS People protected by ITNs 50,000 First-line treatments P er c en t age o <72hours >72 hours 20% Conﬁrmed Cases 0 s 1 2 0 9 7 8 3 6 5 1 4 2 0 3 4 s e 200 201 201 200 200 201 200 200 200 200 201 200 200 200 0% 201 f c a 25,000 2010 2011 2012 2013 2014 People protected by IRS People protected by ITNs <72hours >72 hours N umber o

0 3 2 4 5 8 0 1 6 7 9 1 2 0 3 4 200 200 200 200 200 201 201 200 200 200 200 200 201 201 201

100% 50,000

40,000 80% d s ct e 30,000 s e 60% f c a pro t e 100% 100% 100% 100% 100% 20,000

40% P eop l e 10,000 P er c en t age o 20% 0 1 2 0 9 7 8 3 6 5 1 4 2 0 3 4 200 201 201 200 200 201 200 200 200 200 201 200 200 200 0% 201 2010 2011 2012 2013 2014 People protected by IRS People protected by ITNs <72hours >72 hours Age groups Age groups 50+ 50+ 45-49 years 45-49 years 40-44 years 40-44 years 35-39 years 35-39 years 30-34 years 30-34 years 25-29 years 25-29 years 20-24 years 20-24 years 15-19 years 15-19 years 10-14 years 10-14 years Female Female 5-9 years 5-9 years Male Male Under 5 Under 5

4 2 4 0 2 2 0 4 2 4 Conﬁrmed caseCsonﬁrmed cases

60,000 60,000 30% 30% SPR) SPR) ( 40,000 40,000 20% 20% ( t e t e sitivity R a sitivity R a 20,000 20,000 10% 10% Bl ood Sli de s Ex am i ne d Bl ood Sli de s Ex am i ne d Sli de P o Sli de P o

0 0 0% 0% 0 1 2 3 4 5 6 7 9 8 0 1 2 3 4 5 6 7 9 8 1 0 4 2 3 1 0 4 2 3 201 200 201 201 200 200 200 200 200 200 200 200 200 201 201 201 200 201 201 200 200 200 200 200 200 200 200 200 201 201

Blood Slides ExamBloodine dSlides ExamSPRine d(%) SPR (%)

50,000 50,000 First-line treatmenFirstts-line treatments Conﬁrmed CaseCsonﬁrmed Cases s s s e s e f c a f c a 25,000 25,000 N umber o N umber o

0 0 3 2 4 5 8 0 1 6 7 9 3 2 4 5 8 0 1 6 7 9 1 2 0 3 4 1 2 0 3 4 200 200 200 200 200 201 201 200 200 200 200 200 201 201 201 200 200 200 200 200 201 201 Figure 8. Time from first symptom to treatment Figure 9. People200 200 protected by200 IRS200 and200 by201 ITNs in 201 201 in Costa Rica, 2010-2014 Costa Rica, 2000-2014

100% 100% 50,000 50,000

40,000 40,000 80% 80% d d s s ct e 30,000 ct e 30,000 s e 60% s e 60% f c a pro t e f c a pro t e 100% 100% 100% 100% 100100% 100%20,000 20,000 P eop l e 40% 40% P eop l e 10,000 10,000 P er c en t age o P er c en t age o 20% 20% 0 0 1 2 0 9 7 8 3 6 5 1 4 2 0 3 4 200 201 201 200 200 201 200 200 200 200 201 200 200 200 0% 201 200 1 201 1 200 2 201 2 200 0 201 0 200 9 200 7 200 8 200 3 201 3 200 6 200 5 200 4 0% 201 4 2010 20101 20121 20132 20143 2014 People protectedP eopby IRSle protected by IRSPeople protectedP eopby ITNsle protected by ITNs <72hours <72hour>72s hours >72 hours

Vector Control The last distribution of ITNs occurred in 2013 and Figure 10. Funding for malaria in Costa Rica, currently protect an estimated 11,500 people (Figure 2000-2014 9). Vector control by IRS was not reported in 2014, but has decreased since 2011 as a result of the decline in $7M malaria cases. $6M $5M Funding For decades, the government has provided millions of $4M

$3M dollars in funding for malaria prevention and elimination

(Figure 10). While governmental funding was not US$ (millions) $2M reported in 2014, no less than US$2.5 million have been $1M spent every year since 2000. Although US$200,000 $0M 0 1 2 3 4 5 6 7 8 9 were available from the Global Fund as startup funding 0 1 2 3 4 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 2 0 through the multi-country EMMIE project, around 2 0 2 0 2 0 2 0 2 0 US$20,000 were reported to have been used for Government Global Fund USAID Others malaria at the end of 2014. *Data unavailable for 2014.

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