Report on Situation of Malaria in the Americas, 2008 (Working Document)

Suriname Overview of the malaria Número de casos según especie por municipio. 2008 situation

Suriname is one of the countries of the region which has reported a large reduction in malaria transmission in recent years. Malaria in Suriname has been historically an issue of prime importance in public health, being one of the countries which presented the highest incidence rates in the Americas and the highest proportions of malaria P. falciparum. In the past five years a significant reduction in transmission has been seen; from 14,403 cases in the year 2003 to 1477 cases in 2008.

Suriname has less than half a million inhabitants with the majority living in the coastal areas. The hinterland has areas populated by Amerindians, non- Especie Sum of Casos indigenous “” populations Pf 1 of African descent, and a Pv 10 population of mixed origins 20 (including Brazilian migrants) 30 dedicated to mining activities. 40 There is no malaria transmission 53 on the northern coast of Suriname, where the majority of the population lives. Malaria risk is greatest along the Marowijne River, which borders French Casos por ADM1 Casos a nivel ADM1 Guiana, as well as in areas close to Lake in the northern- ADM1 ADM 1 Pfal+mixtas P. vivax Total casos .. central region where A. darlingi is Sipaliwini 800 633 1,450 .. present.

Brokopondo 32 6 38 .. Three main factors can be attributed to the change in the Para 0 .. situation of malaria: the introduction of therapeutic Grand Total 832 639 1,488 0 500 1000 1500 combinations with artemisinin Número de casos derivatives, a monitoring campaign funded by the Global Fund to intensify prevention and early diagnostic activities, and environmental factors (torrential rainstorns with exceptional floods in 2006) that led to changes in the density of vector.

Country Chapter- Suriname 1 Report on Situation of Malaria in the Americas, 2008 (Working Document)

Número de casos por especie 2000 - 2008 Variaciones interanuales en el número de casos por especie serie año serie año

13,144 2K 11,477 erior 2,496 t 1,725 an 423 10,648 o 184 10K ñ 437 196 261

a 0K 43

9,752 l -444 -378 -355

e -794

casos

con

e 6,877 -1,883 d -3,392 6,693 -2K casos mer o 5K -4,579 en Nú -4,784 2,298 1,673 -4K 1,111 1,6661,709 733 639838 iferencia D 1,229 915 0K 378415 -6K 2000 2001 2002 2003 2004 2005 2006 2007 2008 2000 2001 2002 2003 2004 2005 2006 2007 2008 serie especie Number of P. Fal.. Number of P. Viv..

Número de casos 2000 - 2008 Diferencia (%) con relación al año 2000 serie año serie año

15,922 23% 8% 14,403 0% 0% 0% 2%

15K casos -8% -27% 13,132 12,806 -45% -34% -56% -62% serie

-77%

of -50% -35%

casos

e 10K -37% 8,577 d 8,334 Sum

in -100% -78% mer o -92%

Nú 5K -96% 3,256 ifference 1,477 -150% 807 0K % D 2000 2001 2002 2003 2004 2005 2006 2007 2008 2000 2001 2002 2003 2004 2005 2006 2007 2008

Número de casos de malaria hospi tal izados Despite the marked improvement in the epidemiological serie año situation, malaria continues to affect the unstable 400 377 population of migrants involved in mining activities; the d.. 323 burden of disease in these groups is not completely casos 217 known. Malaria control in this situation, where migrants e

d 200 163 153 act as reservoirs and disseminators of the disease across

mer o the country, is the main challenge for the control 50 36 50 Nú 0 program now.

2000 2001 2002 2003 2004 2005 2006 2007 2008 Trends in morbidity and mortality

Número de muertes por malaria 2000 - 2008 During the 80's there was an increase in the number of serie año malaria cases consequent to an internal armed conflict. In ..

p 24 23 the early 1990s, the increase was caused by the es t 20 18 16 intensification of gold mining and logging activities. The muer outbreaks in 2003 occurred in the south of the country e 10 7 d near the Brazilian border as well as in the eastern 2 1

mer o Marowijne region, which were associated with increased 0 Nú 0 movement of people into gold-mining areas. These activities continue to be the main determinant of

2000 2001 2002 2003 2004 2005 2006 2007 2008 transmission due to displacement of populations in risk areas and the difficulty in ensuring access to health services. Country Chapter- Suriname 2 Report on Situation of Malaria in the Americas, 2008 (Working Document)

Número de casos % del total de casos del país 53 17.1% Apoema 39 29.7% 37 41.6% Kawemhakan 33 52.3% Coordinatie Centrum 25 60.3% Gakaba 21 67.1% Agaigoni 16 72.3% Brokopondo 13 76.5% Pelele Tepoe 10 79.7% 9 82.6% Nason 9 85.5% Afobaka 7 87.7% Gonini 7 90.0% Klaaskreek 6 91.9% Cottica 5 93.5% Victoria 5 95.2% Kwamalasamutu 3 96.1% Apoera 2 96.8% Godoro 2 97.4% Pokigron 2 98.1% Drietabiki 1 98.4% Karmel 1 98.7% Lebidoti 1 99.0% Palumeu 1 99.4% Pikien Saron 1 99.7% Sellakreek 1 100.0% Otros 50.0% 100.0% 01020304050 0% 20% 40% 60% 80% 100% Número de casos % acumulado del total de casos

Municipios según número de casos de malaria Municipios según número de casos de P. falciparum

N casos N casos P. f

51-100 1 11-50 8

11-50 7 6-10 3 6-10 6 1-5 9 1-5 12

Grand Total 26 Grand Total 20

0 5 10 15 20 25 30 0 5 10 15 20 Número de municipios Número de municipios

Municipios según Número de casos, IPA y % de P. falciparum IPA 1.3 100 Victoria Brokopondo 50.0 Apoema 100.0 Nason 80 147.3 Agaigoni Cottica Brownsweg

60 Gakaba Langatabiki Gonini f Kawemhakan %P 40 Afobaka

25 20

0 Kwamalasamutu Pelele Tepoe 250 10 15 20 30 40 50 70 100 150 200 300 Total

Country Chapter- Suriname 3 Report on Situation of Malaria in the Americas, 2008 (Working Document)

Incidencia anual (IPA) por municipio. 2008 Incidencia anual (IPA) y número de casos por municipio Langatabiki 53 38.4 Apoema 39 30.4 Stoelmanseiland 37 9.0 Kawemhakan 33 147.3 Coordinatie Centrum 25 Gakaba 21 14.6 Agaigoni 16 21.4 Brokopondo 13 5.5 Pelele Tepoe 10 18.9 Brownsweg 9 2.3 Nason 9 7.7 Afobaka 7 Gonini 7 8.7 Klaaskreek 6 3.7 Cottica 5 8.3 Victoria 5 10.9 Kwamalasamutu 3 2.9 Apoera 2 1.7 Godoro 2 1.3 Pokigron 2 1.7 Drietabiki 1 0.3 Karmel 1 2.1 Lebidoti 1 0.6 Palumeu 1 3.8 Pikien Saron 1 2.3 Sellakreek 1 Otros 02040600 50 100 150 Número de casos IPA

Sum of Casos Sum of IPA 1 0.0 147.3 The reduction in transmission in recent years has been 10 particularly marked for P. falciparum malaria. For the year 20 2008, the reduction of malaria by this species, with respect 30 to 2000, was 92% and for P. vivax was 62%. The number 40 of cases of severe malaria have been reduced from 377 in 53 2003 to only 50 cases hospitalized in 2008. Equally consistent has been the reduction in mortality such that in the last year no malaria attributed deaths have been reported.

Población según areas de riesgo de transmisión de malaria Dispersion / focalization Medium Risk Malaria-free High Risk ( API Low Risk ( API serie año ( 1/1000 < API Areas (No > 10/1000 ) < 1/1000 ) The transmission is particularly focused around the < 10/1000 ) Indigenous Tr.. Maroijne river along the border with , 2000 19,000 9,000 34,000 355,000 however the number of cases is very low. Lagatabiki, 2001 24,000 22,000 2,000 402,000 with 53 cases, was the district that reported the most 2002 24,000 22,000 2,000 402,000 number cases in 2008 corresponding to 17% of cases in 2003 51,000 0 2,000 397,000 the country. Fifty percent of the cases were from only 2004 51,000 0 2,000 397,000 four districts, all from Maroijne region. The population 2005 51,000 0 2,000 397,000 density is low in Suriname, so despite having very low 2006 46,000 2,000 0 397,000 number of cases malaria incidence continues to be high 2007 46,000 2,000 0 400,000 in respect to other countries. The incidence has reduced 2008 48,000 400,000 significantly compared to levels in the 1990s. In 2008 Suriname reported an incidence rate five times lower than the neighboring countries, Guyana and French Guiana and closer to big countries like Peru and Colombia, which have different epidemiological profile and population patterns. Kawemhakam district in Maroijne, had the highest incidence of malaria in 2008, nearly 150 cases per 1,000 inhabitants, but in general the incidence rate in most Country Chapter- districtsSuriname with the largest number of cases was 4lower to 15 cases per 1,000 Report on Situation of Malaria in the Americas, 2008 (Working Document)

The main foci of transmission are related to mining Número de casos según grupos de edad % del total de casos activity. The mining communities have a high OPS edad OPS edad mobility, moving within the country and to <5 <5 neighboring countries and spreading malaria to 5-14 5-14 other communities. The living and working 15-49 15-49 conditions in mining areas are highly conducive to >50 >50 the proliferation of vectors and an increased exposure of humans to vectors. 0 Número de casos

Malaria in high-risk groups and urban Número de casos según area urbana vs rural % del total de casos areas OPS urbano OPS urbano urbano urbano In Suriname all rural malaria transmission and rural rural major outbreaks are related to transmission in 0 gold miners. The proportion of malaria in children Número de casos younger than 15 years in 2008 was ...... This is compatible with malaria that involves essentially Número de casos em embarazadas % del total de casos adult population because of mining activities. OPS emb OPS emb In 2008 ###### cases of malaria in pregnant Embarazadas Embarazadas women were registered. No embarazadas No embarazadas The proportion of malaria cases that occurred in 0 Amerindians in 2008 was ## % Número de casos The maroon and Brasilian immigrants working in gold mines are among the population group most Número de casos en población indígena % del total de casos affected by malaria, but the disease burden is not OPS ind OPS ind adequately captured by the health system. Indígena Indígena Otro Otro 0 OPS ind casos

% de casos de P. falciparum del total de casos serie año

82.2 79.9 80 75.3 81.1 76.0 77.0 69.9

60 56.2 f 51.4 % P 40

Diagnosis and treatment 20

0 In 2008 28,137 blood slides tests were done in

Suriname, with a positivity rate of 5.3%, which is 2000 2001 2002 2003 2004 2005 2006 2007 2008 one of the lowest among the countries of the Amazon region. The proportion of positive slides Número de tratamientos de ACT distribuidos por año decreased significantly over the decade, which is serie año

compatible with efforts that have been made to d.. ui b improve early detection of cases. Active case ri t detection is one strategy that has been intensified is T d to improve the timeliness of treatment. There are C 0 A

e 0 0 0 0 0 0 0 0 0

mobile units that provide early diagnosis and d initiate the antimalarial treatment. The rapid os tt diagnostic tests (RDTs) is another tool that has e been highly used on recent years. ####### N d examinations were performed in 2008 with RDTs, which allow to start treatment earlier. 2000 2001 2002 2003 2004 2005 2006 2007 2008

Country Chapter- Suriname 5 Report on Situation of Malaria in the Americas, 2008 (Working Document)

Indice de láminas positivas Indice de láminas positivas por ADM1. 2008 serie año Láminas Láminas % láminas ADM1 ADM 1 Examinados Total casos ILP (%) examinadas positivas positivas Sipaliwini 25,692 1,450 5.6 2000 66,443 13,132 19.8 2001 67,369 15,997 23.7 Brokopondo 2,722 38 1.4 2002 67,770 12,837 18.9 2003 70,495 14,906 21.1 2004 56,976 8,379 14.7 2005 59,855 9,131 15.3 2006 45,722 3,289 7.2 2007 30,843 807 2.6 2008 28,137 1,490 5.3

Casos examinados por microscopia y por pruebas rápidas Número de casos diagnóstica dos en las primeras 72 horas del inicio de los síntomas DX metod TDO Año GG RDT 2000 66,443 2001 67,369 2002 67,770 2003 70,495 2004 56,976 2005 59,855 2006 45,722 2007 30,843 2008 28,137 OPS tiempo 0K 50K 0K 50K otro <72 horas Número de casos Número de casos

Casos confirmados vs tratamientos distribuidos In 2004, Suriname introduced the use of AT+LUM as TDO Año TDO tdovsconf first line treatment of P. falciparum malaria and this 2000 casos confirmados policy change has partly led to the dramatic impact on tratamiento d istribuidos the transmission of P. facliparum malaria. Since 2001, 2001 casos confirmados Suriname has implemented a strategy for monitoring tratamiento d istribuidos drug resistance as part of the activities of the Amazon 2002 casos confirmados tratamiento d istribuidos Network for Monitoring Antimalarial Drug Resistance 2003 casos confirmados (RAVREDA) coordinated by PAHO with funding from tratamiento d istribuidos USAID through the AMI project. 2004 casos confirmados tratamiento d istribuidos In terms of treatment, a major difficulty for the control 2005 casos confirmados tratamiento d istribuidos program is to control the use of non-recommended 2006 casos confirmados antimalarials and self-medication by the mining tratamiento d istribuidos population. This practice contributes to the spread of 2007 casos confirmados resistance and the perpetuation of transmission. tratamiento d istribuidos 2008 casos confirmados tratamiento d istribuidos 0K 5K 10K 15K Número de casos / tratamientos

Country Chapter- Suriname 6 Report on Situation of Malaria in the Americas, 2008 (Working Document)

Prevention and control vector Cobertura de rociado residual intradomiciliar INT Año

Currently, long-lasting insecticide treated nets 6K 5,627 as d

(LLINs) are the primary prevention strategy in i g e Suriname. In recent years the program distributed t

pro 4K approximately over 70,000 mosquito nets. It is believed that virtually the entire population in the endemic areas has access to nets. The indoor

personas 2K residual spraying complements insecticide treated e nets (ITNs). During 2008 ###### houses were N d 0K sprayed. 2000 2001 2002 2003 2004 2005 2006 2007 2008 Since the beginning of the decade Suriname has been making progress in implementing the use of Cobertura con mosquiteros de larga duración ITNs, with actions to promote implementation and INT Año sales with community participation. The 47,504 development of LLINs and Global Fund financing has enabled development of this strategy on a large 40K eros t

scale. Handling and washing of the ITNs by the ui population are other aspects of nets that have q mos

demanded specific information and educational e 20K 15,000 14,372 actions. Recently the county has also strengthened N d the capacity for monitoring the residual effect of 7,742 insecticides. 0K 2000 2001 2002 2003 2004 2005 2006 2007 2008

Cobertura con mosquiteros impregnados convencionales INT Año eros t ui q mos

0 e d mer o Nú 2000 2001 2002 2003 2004 2005 2006 2007 2008

Financing malaria control Fuentes de financiamiento FIN ano In the past 4 years most of the funding for malaria control has been through the support of the Global 1000K

Fund. In 2004 the country signed the first draft in $) S

the 4th round of proposals in GFR and in 2007 (U o t another project was accepted for further actions 500K with emphasis on the mining population that Cos contributes significantly to the perpetuation and maintenance of the endemic. USAID, through the 0K AMI project coordinated by PAHO since 2002, has supported technical cooperation in various aspects 2000 2001 2002 2003 2004 2005 2006 2007 2008 of the monitoring program with enhancements that FIN fuente were included in Global Fund projects. e.USAID c.Agencias UN a.Gov. malaria d.Otros b.Fondo Global

Country Chapter- Suriname 7