Part III: Regional Strategies
3. The Americas
Introduction to Malaria in the Region
There are 22 malarious countries in the Americas, located in Central America, around the Amazon Rainforest, in the Caribbean and in southern South America.
Amazon rainforest (9): Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Peru, Suriname and Venezuela
Central America (8): Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama and Mexico
Caribbean (3): Haiti, Dominican Republic and Jamaica
Southern South America (2): Argentina and Paraguay
Population at risk. Approximately 137 million people live in areas at risk of malaria in the Americas, which represents ~4% of the world population at risk.[37]World Malaria Report 2008. Geneva, World Health Organization, 2008.
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Malaria transmission. Approximately 77 million people at risk live in areas of low transmission, with the remainder living in areas where cases exceed 1 per 1000 people. P. vivax is the leading cause of malaria, accounting for 75% of all cases. In the Guyana Shield (French Guiana, Guyana and Suriname), 40-60% of cases are due to P. falciparum. In Mexico and Central America, P. vivax accounts for 94% of the cases. In the Dominican Republic and Haiti, almost 100% of the cases are due to P. falciparum.
Malaria burden. The Americas had an estimated 4 million malaria cases in 2002 (approximately 1% of global incidence), and approximately 1,000 malaria deaths (or less than 0.1% of worldwide deaths).[38]Breman JG et al. Conquering Malaria. In: Jamison DT, Breman JG et al, eds. Disease Control Priorities in Developing Countries Conquering Malaria. Oxford University Press and the World Bank; 2006. p 415.
Click for source During the period from 2000 to 2006, WHO-PAHO estimates that malaria mortality declined by 20%.[39]Based on deaths in the region reported by WHO-PAHO.
Click for source The countries of the Amazon basin bear the brunt of the problem with ~40% of deaths in the Americas occurring in Brazil alone (Figure III.7).
Figure III.7: Malaria cases and deaths in the Americas
Note: Countries with negligible burden are not shown (Argentina, French Guiana, Jamaica, Paraguay, Mexico)
Source: World Malaria Report 2008. Geneva, World Health Organization, 2008
Adapted Approaches and Current Levels of Coverage
Malarious countries in the Americas vary greatly in terms of population size, population at risk, burden, impact of geography on transmission (such as islands and rivers) and success of control programs so far. Within the same country, some areas can be malaria free, while others can be in the control or elimination stage, requiring strong stratification efforts and targeted approaches. In the remainder of this chapter, countries will be classified in the control stage unless an elimination program is being conducted nationwide.
According to WHO, Mexico is in the pre-elimination stage, while Argentina, El Salvador, and Paraguay, are in the elimination stage. Jamaica is in the prevention of reintroduction stage. The remaining 17 countries in the region are currently in the control stage and need to scale-up appropriate preventive and case management interventions to all populations at risk and sustain this level of control. Some countries, such as Ecuador or Nicaragua, have robust control programs. These countries need to maintain the deployment of interventions and scale-up other interventions where coverage is not universal. Figure III.8 presents the country categorization in the region.
The 17 countries currently controlling malaria are using integrated vector management, with a combination of LLINs, IRS and targeted larviciding, as well as case management with diagnosis and timely, appropriate treatment. IPTp is not recommended for pregnant women in this region.
The four countries in pre-elimination or elimination (Mexico, Argentina, El Salvador and Paraguay) rely mainly on active case detection and management of active foci.
Figure III.8: Country categorization in the Americas
Source: World Malaria Report 2008. Geneva, World Health Organization, 2008
Locally adapted approaches to malaria control and elimination. Choosing the appropriate malaria control tools requires a deep understanding of local epidemiology, geography and socioeconomic conditions. In the Americas, the unique features of the region are that it has many areas of low transmission, a high proportion of cases caused by P. vivax, and a number of countries already in elimination. Below is a high level summary of appropriate malaria interventions for these settings. Also see Box III.1 for examples of strong control programs in the region.
Low transmission settings. In several countries of the Americas, levels of transmission are moderate or low. In places where transmission is seasonal or localized in select areas, the use of targeted vector control measures such as IRS or other vector population reduction methods (environmental management, larviciding, etc.) can be very appropriate. As the proportion of fevers due to malaria is low, the use of parasitological diagnosis is essential. Strong capacity to detect and manage epidemics early is required, especially since there is little acquired immunity to protect the populations at risk from developing severe symptoms of malaria.
Dominant P. vivax or mixed settings. Malaria in the Americas is dominated by, P. vivax transmission, which requires adapted tools. Parasitological diagnosis (by microscopy or where not possible RDTs) is essential in areas where both P. vivax and P. falciparum occur. To treat both the blood stage and the liver stage infections of P. vivax, chloroquine combined with 14-days of primaquine is given in places where there is no proven resistance to chloroquine;[40]Guidelines for the Treatment of Malaria. Geneva, World Health Organization, 2006.
Click for source however, compliance to the 14-day regimen is sometimes poor. Vector control interventions do not depend on parasite type; however, P. vivax transmission is often associated with lower malaria transmission levels where IRS can be appropriate. The use of LLINs should be encouraged as well, both for personal protection and as a community protection tool.
Countries in elimination. Proposed approaches for the 5 countries in pre-elimination, elimination and prevention of reintroduction (Mexico, Argentina, El Salvador, Paraguay and Jamaica) are detailed in Part II – Chapter 3: Elimination and Eradication: Achieving Zero Transmission. These approaches mainly focus on the use of targeted vector control interventions (such as IRS) against residual foci as well as active case detection to track and treat remaining cases. These countries have principally P. vivax transmission. Methods for targeting asymptomatic reservoirs are also an important priority.
Current intervention coverage. Many types of interventions have been used in the region with varying degrees of success. These are described below.
LLINs / ITNs. Twelve countries are implementing LLINs as part of their national malaria control strategy, although only 6 of them[41]Bolivia, Guyana, Haiti, Honduras, Nicaragua, Suriname.
are targeting the whole population at risk. Estimates based on data from the WHO World Malaria Report 2008 show that ~585 thousand LLINs / ITNs were in circulation in 2006.[42]GMAP estimates based on data from WHO World Malaria Report 2008 and the Roll Back Malaria Commodity database, 2008.
See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.
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IRS. All countries in the region report use of IRS in targeted areas, but the scale of use is low due to high cost of insecticides. Countries in the region used DDT in the 1960s through the 1980s but are now trying alternative insecticides, such as pyrethroids. Today, none of the countries in the region use DDT. In 2006, approximately 268 thousand households (or ~1.3 million people) were covered by IRS.[43]GMAP estimates based on data from WHO World Malaria Report 2008. See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.
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Other vector control measures. Other vector control measures have been used in several countries, such as environmental management, larvivorous fishes or mosquito proofing of houses. In particular, a regional program[44]Regional Program of Action and Demonstration of Sustainable Alternatives to DDT for Malaria Vector Control in Mexico and Central America (DDT-GEF).
Click for source in Mexico and Central America is coordinating the development of alternative approaches to DDT for vector control with increased community participation in breeding site reduction.
Diagnostics (Microscopy and RDTs). Microscopy is the most widely used method in the region for parasitological confirmation (approximately 7 million diagnoses with microscopy were performed in 2006).[45]GMAP estimates based on data from WHO World Malaria Report 2008. See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.
Click for source Rapid diagnostic tests (RDTs) are available but there is limited data so far on their use.
Anti-malarial treatment. Chloroquine (CQ) and primaquine (PQ) are used as first line treatments against P. vivax infections in all countries in the region. Due to high levels of resistance of P. falciparum to CQ and SP in the Amazon region, ACTs are now first line treatment against P. falciparum in all countries of the Amazon basin apart from French Guiana. There is no evidence of P. falciparum resistance to CQ in Haiti or the Dominican Republic, so CQ is still first-line treatment there. Mexico and Central America continue to use CQ because of very low reported levels of P. falciparum resistance. Approximately 1.1 million treatments for both P. falciparum and P. vivax infections were delivered in 2006.[46]GMAP estimates based on data from WHO World Malaria Report 2008 and the Roll Back Malaria Commodity database, 2008.
See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.
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Box III.1: Examples of strong control programs
- Nicaragua has focused its efforts on strengthening diagnosis and treatment capabilities at the local level with the support of the Global Fund to fight AIDS, Tuberculosis and Malaria (which benefits other diseases as well) and on developing vector control without DDT, for instance with breeding sites reduction through community participation, as part of the project of the Global Environment Facility, supported by the United Nations Environment Programme (UNEP).
- Ecuador has been successfully implementing the 5 key points of the regional strategy developed by WHO - PAHO.[47]The 5 point regional strategy is 1) prevention, surveillance, early detection and containment of epidemics; 2) integrated vector management; 3) diagnosis and treatment; 4) enabling environment; and 5) health systems strengthening. See Regional Strategic Plan for Malaria in the Americas 2006-2010, WHO-PAHO, June 2007.
Click for source - Countries in the Amazon basin have significantly reduced their malaria burden by analyzing P. falciparum resistance patterns and revising their treatment guidelines through the Amazon Network for the Surveillance of Anti-malarial Drug Resistance / Amazon Malaria Initiative which is supported by USAID. See also Box II.5: Scaling Up and Sustaining Control in Brazil in Part II – Chapter 2: Control.
Recommended Regional Approach to Control and Eliminate Malaria
Targets, approaches and priorities must be tailored to the region.
Targets. The Americas have experienced some successes with their control programs: incidence declined 20% between 2000 and 2006, while mortality decreased 70% over the same period.[48]Annual malaria cases and deaths in the Americas, 1998-2006. World Health Organization, WHO-PAHO, November 2007. These estimates are based on reported cases.
Click for source However, opportunities exist to further reduce burden.
To reach universal coverage with appropriate interventions by 2010 in the Americas (See Figure III.9):
- ~17 million LLINs need to be in place in 2010;
- ~5 million of households need to be sprayed with insecticides;
- ~40 million parasitological diagnostics are needed to confirm suspected malaria fever cases; and
- ~2.7 million first-line treatments with chloroquine / primaquine and ACTs are needed.
The Americas contribute little to global deaths and cases, and include a number of countries with advanced malaria control programs. While the RBM targets for 2010 and 2015 are likely not as relevant to the Americas situation, they are still considered the primary targets. In addition, with one country in the pre-elimination stage and three countries in the elimination stage, the Americas will contribute substantially to the RBM elimination targets.
As outlined in Part II: The Global Strategy, an important aspect of achieving targets is through universal coverage with appropriate malaria control interventions for all populations at risk in countries in the control stage, while elimination programs are conducted in countries where feasible.
Figure III.9: Scale-up in interventions from 2006 to 2010 in the Americas
a) Because of 3-year life span, each year approximately 1/3 of the old nets will need to be replaced
b) Actual use is likely not all directed to confirmed malaria cases today
Source: Need based on GMAP costing model; actual based on analysis of World Malaria Report 2008. Geneva, World Health Organization, 2008 and Roll Back Malaria Commodities database
Approaches to main challenges in the region. Challenges faced by countries in their malaria control efforts are varied. However, some common trends can be found that are unique to malaria in the Americas.
Increase access to health services in isolated populations. There are a number of populations with limited access to health services in the Americas. Populations living in remote areas of the Amazon basin have limited access to health services, especially to reliable diagnosis and treatment for malaria. The high travel cost to access health facilities is usually prohibitive for these populations. Access is also limited for mining populations in countries such as Brazil, French Guiana, Guyana and Suriname, and in many areas of Haiti and the Dominican Republic. The most successful and cost-effective way of reaching these populations is to integrate malaria control with other health services. For instance, malaria control can be effectively delivered with the integrated management of childhood illness (IMCI), or the expanded program on immunization (EPI) programs. Most countries in the region offer free LLINs and anti-malarial drugs including ACTs. In addition, the development of community health workers networks to deliver interventions as well as healthcare trainings at the community level can play a powerful role in achieving universal coverage. Brazil, for example, is working to improve access through the deployment of about 40,000 community health workers.
Improve adherence to treatment and proper use of interventions. The proper use of treatment and preventive interventions (such as LLINs) is a barrier to control. One of several causes is that the instructions are not in local dialects or the people are illiterate. To increase adherence, the use of visual tools or messages appropriately adapted to the local culture is required for communication and behavior change programs. Use of community health workers, as is the case in Brazil, can assist with education on proper intervention use.
Monitor drug and insecticide resistance. Drug resistance is a concern in the Amazon region, where P. falciparum is highly resistant to chloroquine and sulphadoxine-pyrimethamine. Chloroquine overall remains effective against P. vivax in the Americas, although some resistance has been reported in Brazil, Colombia, Guatemala, Guyana and Peru.[49]World Malaria Report 2008. Geneva, World Health Organization, 2008.
Click for source All countries have changed their policies to ACTs as the first-line treatment against P. falciparum. As part of the Amazon Malaria Initiative supported by USAID, a network for monitoring drug resistance has been established in 8 countries of the Amazon basin.[50]Amazon Network for the Surveillance of Antimalarial Drug Resistance/Amazon Malaria Initiative (RAVREDA/AMI).
Click for source Resistance to insecticides (particularly DDT) is also a major concern in the region, especially since insecticides are being used in agriculture. Today, all countries have switched away from DDT to pyrethroids. Also several countries are trying to develop alternatives for vector control (e.g. environmental management or breeding site reduction) to the use of DDT. Countries should ensure sufficient monitoring and surveillance is in place so that potential drug and / or insecticide resistance can be identified early, and control strategies can be revised accordingly.
Build managerial capacity. In a major shift over the past decade, countries in the Americas have moved from vertical programs (such as IRS programs) to more decentralized malaria control programs. Effective decentralized programs can often be more responsive to local situations (e.g. increases in incidence due to epidemics, adapting communication and education to local needs, etc.) Unfortunately, this shift has not been accompanied with increased managerial capacity at the local level. In order to run decentralized and locally adapted control programs, skilled staff is needed. Training can play a vital role in developing critical skills such as program management and financing. Parallel to training is the empowerment of program managers through provision of information, knowledge and decision-making authority. These are key characteristics of the effective decentralized program that has been implemented in Brazil. To effectively implement similar programs, countries and districts should focus on skill development training combined with increased responsibility, authority and information given to local-level managers.
Foster cross-country coordination. Significant information exchange and various forms of innovative partnerships are in effect between and among countries in the region. However, strengthening of these relations becomes all the more crucial as countries move towards malaria elimination. The strength of current malaria sub-regional networks in the Amazon and in Mexico and Central America must be sustained and needs to inherently evolve according to emerging/re-emerging issues that confront them. Bi- and multi-lateral coordination among countries that share common borders with malarious areas (e.g. Brazil, French Guiana and Suriname) should be fostered.
Expand research. More operational research needs to be conducted to validate appropriateness of tools for different settings, and to validate country strategies and policies. In addition, development of effective interventions suitable for outdoor-biting vectors would be highly beneficial to countries in the Americas, where many of these mosquitoes exist.
Strengthen M&E and information systems. M&E and information systems are crucial for malaria control program success, and become even more important as country programs evolve from sustained control to and through elimination. Many countries in the Americas have a system in place; however the quality and relevance of data collected requires improvement. Countries would benefit from guidelines and instructions: one option is for countries to collaborate closely with WHO - PAHO and MERG to optimize M&E programs for their countries until further guidelines and indicators are developed.
Strategic priorities. Due to the relatively moderate or low malaria burden in countries within this region, none of the highest burden countries that account for most of the malaria deaths are located in the Americas.
Within the region, the burden is highly concentrated within eight countries (Brazil, Colombia, Haiti, Peru, Guyana, Venezuela, Dominican Republic and Suriname), which account for ~98% of estimated malaria deaths in the Americas (see Figure III.10). However, cases and deaths alone do not provide the complete story: comparing deaths to population at risk over time shows a different picture for Brazil, which has experienced significant declines in death rates due to successful control programs. Still, it is important to provide assistance to all malarious countries in the Americas, even if burden varies. Countries with extremely high burden need attention and assistance, as do countries which have achieved levels of control but need help sustaining it, and countries which are pursuing elimination and which would benefit from technical assistance and other support.
Figure III.10: Distribution of malaria deaths in the Americas
Source: World Malaria Report 2008. Geneva, World Health Organization, 2008
To reach the 2010 targets, several factors must be taken into account.
- High contribution to regional deaths. Brazil, Colombia and Haiti comprise ~85% of the malaria deaths in the Americas. Haiti in particular has a high burden relative to its small population at risk.
- Supporting ongoing control and elimination programs. While efforts are made to lower burden in the highest mortality countries, continued support should be provided to countries which have achieved significant burden reductions, as well as countries embarking on elimination campaigns.
As for priorities beyond 2010, with many countries in the Americas having made significant progress in their control programs, the key priorities will be to sustain the reductions in morbidity and mortality. For countries in sustained control, this will include continued financing of malaria control programs from both country budgets and external donors. Improved M&E to identify epidemics early, as well as potential emergence of resistance, should also be an important part of these countries’ strategies. Strengthening management capacity through training and empowerment of decentralized program managers will ensure these countries have the systems in place to eventually embark on an elimination program.
Countries in the pre-elimination and the elimination stage are encouraged to push towards bringing local transmission to zero, and to undertake operational research and share best practices with countries in- and outside the region. These countries will likely need to increase emphasis on cross-border collaboration and on minimizing transmission from transient populations.
To date, the RBM Partnership not been actively engaged in supporting countries or partners in the Americas. The RBM Partnership may want to establish a focal point to act as a formal interface with the region. The Partnership could play a valuable role by providing opportunities to share and learn best practices from other regions. The active cooperation networks that started in the region (such as the network on drug resistance monitoring) need to be maintained and strengthened.
RBM partners will provide to all countries in the control or elimination stage the general support detailed in Part II: The Global Strategy of the plan. Specifically, Brazil, Columbia and Haiti, the countries with the greatest malaria mortality, could be supported by additional technical assistance (e.g. for planning, development of fund proposals, resolving implementation bottlenecks, strengthening M&E systems) to achieve targets. Countries that are more focused on sustaining control programs, such as Brazil, must be assisted in maintaining milestones achieved and in moving towards possible malaria elimination through improved health management information systems (HMIS), management capacity, and access.
Funding Requirements: US$ 83 million gap for 2010
As illustrated in Figure III.11, an estimated US$ 178 million was disbursed for malaria programs in 2007 in the Americas. Approximately 91% of this funding came from national budgets, the highest rate for all four regions. The remaining disbursements came from international donors, above all the Global Fund (~9%). The Global Fund has awarded grants worth ~US$ 90 million to 11 countries in the region, including a multi-country proposal for four Andean countries. The Andean countries (US$ 25 million), Haiti (US$ 14 million) and Guatemala (US$ 14 million) received the largest grants. Other main donors include USAID (US$ 8.8 million) and the United Nations Environmental Program (US$ 13 million).
Figure III.11: Gap in malaria funding in the Americas
Note: See appendices on methodologies to estimate costing needs and current funding
Source: GMAP costing model (WHO, GFATM, World Bank, PMI)
The Americas comprise approximately 4% of the world’s population at risk and 4% of the total global costs to scale-up. This relatively lower level is due to the large proportion of the population living at low risk, as well as the significant progress made so far in many countries’ control efforts. Approximately US$ 227 million is needed in 2009 and US$ 261 million is needed in 2010 to scale-up preventive and curative interventions in the Americas to reach target coverage levels (see Table III.3). Compared to current investment levels, there is an estimated funding shortfall of US$ 83 million to reach 2010 funding needs, which is the smallest funding gap of all regions.
Table III.3: Summary of annual costs in the Americas
| Cost category (US$ millions) | 2009 | 2010 | 2015 | 2020 | 2025 |
| LLINs/ITNs | 66 | 66 | 46 | 49 | 1 |
| IRS | 43 | 62 | 66 | 65 | 55 |
| IPTp | 0 | 0 | 0 | 0 | 0 |
| Prevention cost | 109 | 128 | 113 | 114 | 56 |
| RDTs | 23 | 28 | 8 | 0 | 0 |
| ACTs | 1 | 1 | 0 | 0 | 0 |
| Chloroquine and primaquine | 1 | 1 | 0 | 0 | 0 |
| Severe case management | 0 | 0 | 0 | 0 | 0 |
| Case management cost | 24 | 30 | 9 | 0 | 0 |
| Community health workers | 4 | 4 | 5 | 4 | 2 |
| Training | 28 | 27 | 26 | 26 | 10 |
| M&E and OR | 23 | 27 | 27 | 27 | 36 |
| Infrastructure / inst. strengthening | 39 | 45 | 46 | 47 | 17 |
| Program cost | 94 | 103 | 104 | 104 | 64 |
| Total control & elimination cost | 227 | 261 | 226 | 219 | 120 |
Note: Diagnostic costs are covered both by RDTs in case management and by microscopy in infrastructure / institutional strengthening
Source(s): GMAP costing model; Johns B. and Kiszewski A. et al
