MALARIA IN THE AMERICAS AND THE MILLENIUM DEVELOPMENT GOALS

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1 MALARIA IN THE AMERICAS AND THE MILLENIUM DEVELOPMENT GOALS Dr. Keith H. Carter Regional Malaria Advisor PAHO/WHO Recife, 14 April 2004

2 MALARIA CONTROL PROGRAMS OBJECTIVE: Prevent mortality and reduce morbidity associated with the disease

3 MALARIA PARASITES IN THE AMERICAS Plasmodium vivax : most prevalent Plasmodium falciparum : most pathogenic Plasmodium malariae : Suriname Plasmodium ovale : occasionally imported

4 Malaria Transmission: Mexico, Central America and One Island Mexico Belize Dominican Republic Haiti Honduras Guatemala Nicaragua El Salvador Costa Rica Panama P. vivax: : 95% cases. Haiti and Dominican Republic: P. falciparum Guatemala, Honduras, Nicaragua: 85% of cases in Central America

5 Malaria Transmission in South America: All except Chile and Uruguay CHILE URUGUAY

6 Malaria in South America Principal Parasite: Plasmodium vivax Brazil 77% of all cases Bolivia, Colombia, Peru, Ecuador, Venezuela 68% of all cases Suriname, Guyana, French Guiana 37% of all cases

7

8 EFFORTS TO COMBAT MALARIA MALARIA ERADICATION ERA (1955) GLOBAL MALARIA CONTROL STRATEGY (1992) ROLL BACK MALARIA INITIATIVE 1998 GLOBAL FUND AIDS/TB/MALARIA

9 LOBAL MALARIA CONTROL STRATEGY 1992 LEMENTS: EARLY DIAGNOSIS, PROMPT TREATMENT SELECTIVE AND SUSTAINABLE PREVENTIVE MEASURES INCLUDING VECTOR CONTROL DETECTION, CONTAINMENT OF EPIDEMICS OPERATIONAL RESEARCH: INCLUDING ECOLOGICAL SOCIAL AND ECONOMIC DETERMINANTS

10 MALARIA VECTOR CONTROL INSECTICIDE TREATED BEDNETS: INDIVIDUAL AND MASS EFFECT LARVAL CONTROL (BIOLOGICAL, CHEMICAL) ENVIRONMENTAL MANAGEMENT INDOOR RESIDUAL SPRAYING (STOCKHOLM) Other Vector borne diseases: DENGUE, FILARIASIS, YELLOW FEVER, CHAGAS etc. (INTEGRATED VECTOR MANAGEMENT) Multiple methods, sectors, diseases

11 Malaria in the Americas, ,400,000 1,200,000 1,000, , , , , Positive P. vivax P. falciparum

12 Malaria in the Americas: Case Distribution by Parasite, ,000, , , , , , , , , , P. vivax P. falciparum

13 140, , ,000 80,000 60,000 40,000 20,000 Malaria: Case Distribution by Age Group and Gender (Americas, 2002) 0 < 1 yr 1-4 yrs 5-14 yrs yrs 50+ Female Male

14 MALARIA CASE DISTRIBUTION IN THE AMERICAS, 2002 BRASIL 40% (349,873) COLOMBIA 22% (195,719) ECUADOR 10% (86,757) PERU 10% (85,742) GUATEMALA 4% (35,540) VENEZUELA 3% (29,491) GUYANA 2.5% (21,895) HONDURAS 2% (17,223) SURINAME 1.5% (13,091)

15 Malaria Parasitic Indices by Geographic Subregion, AVI: Cases of P. vivax per 1,000 population n high and moderate risk areas AFI: Cases of P. falciparum per 1,000 population in high an moderate risk areas 0 Guyana, Fr. Guiana, Suriname Brazil Andean CAPB Haiti, Dominican Republic Southern Cone AVI AFI

16 MALARIA BURDEN DEATHS: Associated with P. falciparum 816 in in 2002 FATALITY RATE: Dominican Republic, Nicaragua, Haiti, Peru, Brazil, Colombia, MORBIDITY: 1,233,000 cases in ,000 cases in 2002

17 Malaria Cases and Expenditure in 13 Countries, ,200, ,000, ,000,000 1,000, ,000,000 Cases 800, , , ,000, ,000, ,000,000 80,000,000 60,000,000 US Dollars 200,000 40,000,000 20,000, Year 0 Cases Total Funds

18 Malaria Cases and Expenditure per capita at Risk in 13 Countries, Malaria Cases Funds per capita at risk Year 0 Cases Funds/Pop. At risk

19 PROGRESS REDUCTION IN MORTALITY, MORBIDITY INTEGRATION INTO HEALTH SERVICE EPIDEMIOLOGICAL STRATIFICATION OPERATIONAL RESEARCH

20 RESISTANCE TO ANTIMALARIALS P.vivax First Confirmation of Resistance to Chloroquine in Indonesia and Papua New Guinea (1989) Subsequent but isolated and sporadic reports (individual patients or small numbers: Brasil, Guatemala, Guyana, India, Myanmar, Peru, Solomon Islands

21 RESISTANCE TO ANTIMALARIALS P.falciparum First suspected resistance Thailand (1957) Confirmed in patients Colombia (1958) Since then worldwide dissemination Sensitivity to Chloroquine in Mesoamerica

22 Antimalarial Drug Resistance Suspected / Reporte Venezuela CQ,SP Colombia CQ; SP Ecuador CQ Peru CQ; SP Suriname CQ Guyana CQ; SP French Guian CQ; SP Brazil QU; CQ; SP; MQ Bolivia CQ; SP QU = Quinine CQ = Chloroquine SP = Sulfadoxine/Pyrimethamine MQ = Mefloquine

23 DEVELOPMENT OF RAVREDA / AMI COUNTRIES IDENTIFY NEED TO DEVELOP AN AMAZON NETWORK FOR SURVEILLANCE OF ANTIMALARIAL DRUG RESISTANCE (RAVREDA): Brasil,, USAID AGREES TO FINANCIALLY SUPPORT ESTABLISHMENT OF RAVREDA AS PART OF ITS AMAZON MALARIA INITIATIVE (AMI) NETWORK COORDINATION: PAHO AND USAID PARTICIPATION OF 8 COUNTRIES, PAHO, WHO, USAID, CDC, USP, MSH (RPM-PLUS) PLUS)

24 ACTIVITIES AT COUNTRY AND REGIONAL LEVEL COUNTRY REGIONAL NATIONAL COMMITTEE COORDINATOR AND WORK PLANS IDENTIFICACION SENTINEL SITES EFFICACY TRIALS USE OF RESULTS COORDINATION STEERING COMMITTEE TECHNICAL COOPERATION

25 AMAZON NETWORK FOR MONITORING ANTIMALARIAL DRUG RESISTANCE (RAVREDA) Sentinel Site FUNDED BY USAID: AMAZON MALARIA INITIATIVE

26 Drug Policy changes for P. falciparum in the Amazon Region CoArtem MQ + AS SP+AS T AMO+AS MQ Q+D,T T T Q T AMO+SP CQ+SP CQ o SP Country Bolivia Peru Guyana Suriname Venezuela

27 Drug Policy changes for P. falciparum in the Amazon Region CoArtem M + AS SP+AS AMO+AS M Q+D,T Q AMO+SP CQ+SP T CQ o SP Country Brasil Ecuador Colombia

28 THE FUTURE? IMPLEMENTATION RESEARCH OTHER ELEMENTS OF MALARIA CONTROL ROLL BACK MALARIA / MILLENIUM DEVELOPMENT GOALS

29 MILLENIUM DEVELOPMENT GOAL : SOME FACTORS HEALTH SYSTEM DEVELOPMENT: ACCESS TRAINED PROVIDERS INFORMATION SYSTEM, EPIDEMIOLOGY DISSEMINATION COMMUNICATION (TARGET RISK GROUPS, CREATE AWARENESS) TREATMENT COST, ACCEPTABILITY, COMPLIANC RAPID DIAGNOSTIC TESTS MALARIA IN PREGNANCY DRUG QUALITY AND DISTRIBUTION SYSTEM INSECTICIDE RESISTANCE INSECTICIDE TREATED MATERIALS (IVM) IMPLEMENTATION RESEARCH USE OF RESULTS IN DECISION MAKING MANAGERIAL CAPACITY

30 IMPLICATIONS FOR HEALTH SYSTEMS Technically efficacious tools Failure not on intervention but on application Health System failure to achieve potential due to limitations to provide service than tools (WHO 2000)

31 RELEVANCE OF HEALTH SYSTEM EFFICACY X COVERAGE = EFFECTIVENESS DRUG EFFICACY 95% COVERAGE: HEALTH SYSTEM FACTORS (MCP ETC.) ACCESS 80% TARGETTING (setting, timing, groups) 80% PROVIDER COMPLIANCE (charging? dosing) 80% PATIENT ADHERENCE (illiteracy, cost etc.) 70 % POVERTY : POOR AFFECTED MORE BY FACTORS EFFECTIVENESS = 34 %

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