MALARIA IN PARAGUAY Current scenario and forecasting system

MALARIA IN PARAGUAY Current scenario and forecasting system

Antonieta Rojas de Ariasarias1@telesurf.com.py

Antonieta Rojas de Ariasarias1@telesurf.com.py

2005

OrganizaciónPanamericanade la Salud

MALARIA IN THE AMERICAS: historical summary (1900-1950’S)

MALARIA IN THE AMERICAS: historical summary (1900-1950’S)

• At the beginning of the 20th century: malaria transmission by the entire continent

• 1902: foundation of the Pan American Sanitary Bureau; malaria was one of the most prevalent infectious diseases

• 1942: malaria was considered the most harmful disease in continent

• 1948: great success in the reduction in the incidence of malaria and in the elimination of the transmission in some areas, thanks to the DDT

• 1954: malaria eradication campaign in the Americas • 1955: the campaign of eradication is made at the world

level

• At the beginning of the 20th century: malaria transmission by the entire continent

• 1902: foundation of the Pan American Sanitary Bureau; malaria was one of the most prevalent infectious diseases

• 1942: malaria was considered the most harmful disease in continent

• 1948: great success in the reduction in the incidence of malaria and in the elimination of the transmission in some areas, thanks to the DDT

• 1954: malaria eradication campaign in the Americas • 1955: the campaign of eradication is made at the world

level

2005

OrganizaciónPanamericanade la Salud

MALARIA IN THE AMERICAS: historical summary (1960- up to now)

MALARIA IN THE AMERICAS: historical summary (1960- up to now)

• Decade of 1960: interruption of the malaria transmission in the Caribbean, except in Hispaniola

• 1992: `Global malaria control strategy`; the emphasis passes of the eradication to the control

• 1998: roll back malaria (RBM); reduce to half morbidity and mortality by malaria for 2010

• 2000: the Member States of PAHO adopt the resolution for roll back malaria 2000: Millennium Development Goals, of the United Nations: "… Have stopped and begun to reduce, for the year 2015, the spread of HIV/AIDS, tuberculosis and malaria"

• Decade of 1960: interruption of the malaria transmission in the Caribbean, except in Hispaniola

• 1992: `Global malaria control strategy`; the emphasis passes of the eradication to the control

• 1998: roll back malaria (RBM); reduce to half morbidity and mortality by malaria for 2010

• 2000: the Member States of PAHO adopt the resolution for roll back malaria 2000: Millennium Development Goals, of the United Nations: "… Have stopped and begun to reduce, for the year 2015, the spread of HIV/AIDS, tuberculosis and malaria"

2005

OrganizaciónPanamericanade la Salud

MALARIA CURRENT SITUATIONMALARIA CURRENT SITUATION

264 of the 869 million inhabitants of the American hemisphere live in ecological risk areas of malaria transmission (2004)

Very low or low risk areas: 223 million

Moderate risk areas : 30 million

High risk areas: 11 million

264 of the 869 million inhabitants of the American hemisphere live in ecological risk areas of malaria transmission (2004)

Very low or low risk areas: 223 million

Moderate risk areas : 30 million

High risk areas: 11 million

2005

OrganizaciónPanamericanade la Salud

Distribution of population* according to risk

area, in the Americas

Population at moderate risk areas30,391

Moderate Risk

Population at high risk 11,145

High Risk

Population at low risk 222,603

Low Risk*millons (2004)

2005

OrganizaciónPanamericanade la Salud

REPORTED CASES OF MALARIA(1998-2004)

REPORTED CASES OF MALARIA(1998-2004)

• Morbidity (2004):

• 882,360 cases • 74% due to P.

vivax • 23.3%

reduction in cases compared with 2000

• 21% reduction in moderate and high risk areas

• Morbidity (2004):

• 882,360 cases • 74% due to P.

vivax • 23.3%

reduction in cases compared with 2000

• 21% reduction in moderate and high risk areas

0

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2005

OrganizaciónPanamericanade la Salud

DEATHS ATTRIBUTED TO MALARIA(1998-2004)

DEATHS ATTRIBUTED TO MALARIA(1998-2004)

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Total de defunciones 372 185 301 219 168 99 96

1998 1999 2000 2001 2002 2003 20040

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100

150

200

250

300

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400

Total de defunciones 372 185 301 219 168 99 96

1998 1999 2000 2001 2002 2003 2004

• Mortality (2004): 156 deaths • 55% reduction in attributable deaths to malaria since 2000 • Reduction in case-fatality rate of 13 per 10,000 to 7 per

10,000 cases P. falciparum

• Mortality (2004): 156 deaths • 55% reduction in attributable deaths to malaria since 2000 • Reduction in case-fatality rate of 13 per 10,000 to 7 per

10,000 cases P. falciparum

2005

OrganizaciónPanamericanade la Salud

PARAGUAY: Population at Risk of Malaria Transmission, 1998-2004 (in thousands)PARAGUAY: Population at Risk of Malaria Transmission, 1998-2004 (in thousands)

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2000

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Population at Risk 3035 3108 3185 2193 2391 1972 3049

Total Population 5222 5358 5496 5634 5774 5917 5917

1998 1999 2000 2001 2002 2003 20040

1000

2000

3000

4000

5000

6000

Population at Risk 3035 3108 3185 2193 2391 1972 3049

Total Population 5222 5358 5496 5634 5774 5917 5917

1998 1999 2000 2001 2002 2003 2004

2005

OrganizaciónPanamericanade la Salud

PARAGUAY: Population at Ecological Risk of Malaria Transmission According to Level of

Transmission Risk , 1998-2004 (in thousands)

PARAGUAY: Population at Ecological Risk of Malaria Transmission According to Level of

Transmission Risk , 1998-2004 (in thousands)

0

500

1000

1500

2000

2500

Low Risk 905 1048 1054 1291 834 1492 1263

Moderate Risk 914 2060 818 752 1557 480 1786

High Risk 1216 … 1313 150 0 0 0

1998 1999 2000 2001 2002 2003 20040

500

1000

1500

2000

2500

Low Risk 905 1048 1054 1291 834 1492 1263

Moderate Risk 914 2060 818 752 1557 480 1786

High Risk 1216 … 1313 150 0 0 0

1998 1999 2000 2001 2002 2003 2004

2005

OrganizaciónPanamericanade la Salud

PARAGUAY: Malaria Morbidity, 1998-2004 (number of positive blood slides)

PARAGUAY: Malaria Morbidity, 1998-2004 (number of positive blood slides)

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10000

No. of Cases 2091 9947 6853 2710 2778 1392 694

1998 1999 2000 2001 2002 2003 20040

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2000

3000

4000

5000

6000

7000

8000

9000

10000

No. of Cases 2091 9947 6853 2710 2778 1392 694

1998 1999 2000 2001 2002 2003 2004

2005

OrganizaciónPanamericanade la Salud

PARAGUAY: Malaria Morbidity According to Level of Transmission Risk, 1998-2004 (number of positive blood

slides)

PARAGUAY: Malaria Morbidity According to Level of Transmission Risk, 1998-2004 (number of positive blood

slides)

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

Low Risk 8 188 17 798 193 837 14

Moderate Risk 16 9744 1333 1107 2563 525 677

High Risk 2048 … 5493 777 0 0 0

Originally Non-Malarious 19 15 10 28 22 30 3

1998 1999 2000 2001 2002 2003 20040

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

Low Risk 8 188 17 798 193 837 14

Moderate Risk 16 9744 1333 1107 2563 525 677

High Risk 2048 … 5493 777 0 0 0

Originally Non-Malarious 19 15 10 28 22 30 3

1998 1999 2000 2001 2002 2003 2004

2005

OrganizaciónPanamericanade la Salud

PARAGUAY: Malaria Morbidity According to Parasite Species (In All Risk Areas), 1998-2004

PARAGUAY: Malaria Morbidity According to Parasite Species (In All Risk Areas), 1998-2004

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

In All Risk Areas … … … 1.23 1.16 0.7 0.23

Moderate and High Risk Only 0.97 4.79 3.22 2.09 1.78 1.09 0.38

1998 1999 2000 2001 2002 2003 20040

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

In All Risk Areas … … … 1.23 1.16 0.7 0.23

Moderate and High Risk Only 0.97 4.79 3.22 2.09 1.78 1.09 0.38

1998 1999 2000 2001 2002 2003 2004

2005

OrganizaciónPanamericanade la Salud

PARAGUAY: Passive vs. Active Case Detection, 1998-2004 (% of Blood Slides Examined)

PARAGUAY: Passive vs. Active Case Detection, 1998-2004 (% of Blood Slides Examined)

63

.82

53

.42

59

.84

51

.04

43

.22

42

.15

43

.79

36

.18

46

.58

40

.16

48

.96

56

.78

57

.85

56

.21

0 20 40 60 80 100 120

1998

1999

2000

2001

2002

2003

2004

Passive Active

63

.82

53

.42

59

.84

51

.04

43

.22

42

.15

43

.79

36

.18

46

.58

40

.16

48

.96

56

.78

57

.85

56

.21

0 20 40 60 80 100 120

1998

1999

2000

2001

2002

2003

2004

Passive Active

2005

OrganizaciónPanamericanade la Salud

PARAGUAY: Annual Blood Examination Rate (ABER) in Malarious Areas, 1998-2004

PARAGUAY: Annual Blood Examination Rate (ABER) in Malarious Areas, 1998-2004

3035000

3108000

3185000

2193000

2391000

1972000

3049000

42934

101074

97026

76607

99338

126528

97246

1998

1999

2000

2001

2002

2003

2004

Examined

Population at Risk / In Malarious Areas

3035000

3108000

3185000

2193000

2391000

1972000

3049000

42934

101074

97026

76607

99338

126528

97246

1998

1999

2000

2001

2002

2003

2004

Examined

Population at Risk / In Malarious Areas

2005

OrganizaciónPanamericanade la Salud

PARAGUAY: Slide Positivity Rate (SPR), 1998-2004

PARAGUAY: Slide Positivity Rate (SPR), 1998-2004

2091

9947

6853

2710

2778

1392

694

42934

101074

97026

76607

99338

126528

97246

1998

1999

2000

2001

2002

2003

2004

Examined

Positive

2091

9947

6853

2710

2778

1392

694

42934

101074

97026

76607

99338

126528

97246

1998

1999

2000

2001

2002

2003

2004

Examined

Positive

2005

OrganizaciónPanamericanade la Salud

PARAGUAY: Antimalarial Drugs Used, 1998-2004PARAGUAY: Antimalarial Drugs Used, 1998-2004

0

50000

100000

150000

200000

250000

300000

350000

400000

Chloroquine &/or Amodiaquine @ 150mg … 356000 330244 282900 251775 341973 288328

Primaquine @ 15mg … 211607 173466 40535 51341 35186 15596

Sulfa/Pyrimethamine @ 500/25mg … … … … … … …

Mefloquine @250mg … … … … … … …

Artemisinine Derivatives (# of Tx) … … … … … … …

Quinine @ 300mg … … … … … … …

1998 1999 2000 2001 2002 2003 20040

50000

100000

150000

200000

250000

300000

350000

400000

Chloroquine &/or Amodiaquine @ 150mg … 356000 330244 282900 251775 341973 288328

Primaquine @ 15mg … 211607 173466 40535 51341 35186 15596

Sulfa/Pyrimethamine @ 500/25mg … … … … … … …

Mefloquine @250mg … … … … … … …

Artemisinine Derivatives (# of Tx) … … … … … … …

Quinine @ 300mg … … … … … … …

1998 1999 2000 2001 2002 2003 2004

2005

OrganizaciónPanamericanade la Salud

PARAGUAY: National Budget and Non-Budgetary Contributions to Malaria Control Programs, 1998-

2004 (in US$)

PARAGUAY: National Budget and Non-Budgetary Contributions to Malaria Control Programs, 1998-

2004 (in US$)

1

10

100

1000

10000

100000

1000000

10000000

Contributed Funds and Loans

National Malaria Budget

Total Budget

Contributed Funds andLoans

… 21281 … … … 175000 202404

National Malaria Budget 7501159 4338457 1932103 1061490 1126149 1164935 1147905

Total Budget 7501159 4359738 1932103 1061490 1126149 1339935 1350309

1998 1999 2000 2001 2002 2003 20041

10

100

1000

10000

100000

1000000

10000000

Contributed Funds and Loans

National Malaria Budget

Total Budget

Contributed Funds andLoans

… 21281 … … … 175000 202404

National Malaria Budget 7501159 4338457 1932103 1061490 1126149 1164935 1147905

Total Budget 7501159 4359738 1932103 1061490 1126149 1339935 1350309

1998 1999 2000 2001 2002 2003 2004

2005

OrganizaciónPanamericanade la Salud

PARAGUAY: Annual $US Funds / Person in Malarious Areas, 1998-2004

PARAGUAY: Annual $US Funds / Person in Malarious Areas, 1998-2004

0

0,5

1

1,5

2

2,5

$US Funds / Person in Malarious Area 2,47 1,4 0,61 0,48 0,58 0,68 0,44

1998 1999 2000 2001 2002 2003 20040

0,5

1

1,5

2

2,5

$US Funds / Person in Malarious Area 2,47 1,4 0,61 0,48 0,58 0,68 0,44

1998 1999 2000 2001 2002 2003 2004

THE VICTIMSTHE VICTIMS

Tendencia de Control de PaludismoParaguay-2000/2005*

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ene feb mar abr may jun jul ago set oct nov dicmeses

ca

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Lim.Sup Lim.Medio 2000 2001

2002 2003 2004 20052005* Datos parciales hasta noviembreCurva Endem: 2000/2004

FUENTE: SECC.ESTADISITCA - SENEPA

Epidemia

Alarma

Control

Malaria in 2005Malaria in 2005

Corridor of TransmissionCorridor of Transmission

CANINDEYÚ

CAAGUAZÚ

ALTO

PARANÁ

CLIMATIC CONDITION BEHAVIOUR IN 2010CLIMATIC CONDITION BEHAVIOUR IN 2010

Va

lor

de

l IB

-2.0

-1.5

-1.0

-0.5

0.0

0.5

1.0

1.5

2.0

-2.0

-1.5

-1.0

-0.5

0.0

0.5

1.0

1.5

2.0

EN

E

FE

B

MA

R

AB

R

MA

Y

JUN

JUL

AG

O

SE

P

OC

T

NO

V

DIC

IB1-L. Base

IB1-C.Actuales

IB1-2010

Proyección del Paludismo para el 2010, bajo condiciones de intervención

y sin intervención epidemiológica respecto a línea base y condiciones actuales

Pa

tró

n m

ed

io

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C. Actuales

Proyección-1

Proyección-2

HISTORIAL SERIES OF MALARIA CASES

1988: 2884 cases 1997: 567 cases 1999: 9946 cases

2000: 6853 cases : 7.1 % slides (97,026)2001: 2706 cases : 3.8 % slides (71,708)2002: 2778 cases : 2.8 % slides (99,338)

2003: 1235 cases: 0.9 % slides (126,528) 2004: 694 cases: 0.7 % slides (97,246) 2005: 376 cases: 0.4 % slides ( 85,942)

Anopheles spp. (A. darlingi and others)

THE VECTORTHE VECTOR

INTRADOMICILE EXTRADOMICILEAn.darlingi X XAn.albitarsis X XAn. strodei X XAn.trianulatus X XAn.noroestenci X XAn.brasiliensis X XAn.rondoni X XAn.argyrytarsis X XAn. osvaldoi X XAn.galvaoi X XAn.lanei XAn.parvus X XAn.lutzi X XAn. antunesis X XAn.punctimacula XAn.mediopuntatus X XAn. fluminensis X XAn. neomaculipalpus XAn. apicimácula XAn.minor X XAn.pseudopuntipennis XAn. peryassui X

ANOPHELINE SPECIES BREEDING SITES IN PARAGUAY

ANOPHELINE SPECIES BREEDING SITES IN PARAGUAY

Fuente: Secc.Entomología - SENEPA

MALARIA CASES AND ANOPHELINE DENSITIES MALARIA CASES AND ANOPHELINE DENSITIES

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ENE FEB MAR ABR MAY JUN JUL AGO SET OCT NOV DIC

MES

NR

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E C

AS

OS

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EJE

MP

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ES

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nro. de casos An.(N) darlingi An.(N) albitarsis An.(N) strodei Otros anofeles

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ENE FEB MAR ABR MAY JUN JUL AGO SET OCT NOV DIC

MES

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nro. de casos An.(N) darlingi An.(N) albitarsis An.(N) strodei Otros anofeles

Fuente: Secc.Estadística-SENEPA

2005

OrganizaciónPanamericanade la Salud

THE ENVIRONMENTTHE ENVIRONMENT

HISTORICAL SERIES OF CASES 1966-2000

HISTORICAL SERIES OF CASES 1966-2000

Años

Ca

so

s d

iag

no

stica

do

s

-100

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19

66

19

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19

75

19

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19

85

19

90

19

95

19

99

• Epidemiological variables– Total monthly cases 1966-1998; Baseline: 1966-70 and 1985-1990:

control line: 1971-1984. Current conditions: 1992-1998.

• Climatic variables – Temperature max, medium y min; Daily termical Oscillation, monthly

precipitations

• Epidemiological variables– Total monthly cases 1966-1998; Baseline: 1966-70 and 1985-1990:

control line: 1971-1984. Current conditions: 1992-1998.

• Climatic variables – Temperature max, medium y min; Daily termical Oscillation, monthly

precipitations

INFORMATIVE BASELINEINFORMATIVE BASELINE

METHODOLOGYMETHODOLOGY

Use of empirical-statistical models for the malaria projection

• Model regressive auto with non-constant variance (with index of parcel).

Analysis of time series + statistics multivariate-analysis of the principal components (ACP)

Verification of the modelsValidation of the models empirical-statistical Analyses of sensitivity of the models

Use of empirical-statistical models for the malaria projection

• Model regressive auto with non-constant variance (with index of parcel).

Analysis of time series + statistics multivariate-analysis of the principal components (ACP)

Verification of the modelsValidation of the models empirical-statistical Analyses of sensitivity of the models

METHODOLOGY: CLIMATE CHANGE SCENARIOS

METHODOLOGY: CLIMATE CHANGE SCENARIOS

• General circulation models: - UKTR - CCCEQ - hadcm2.

• Climatic sensitivities: - 1.5 ºc (decline) - 2.5 ºc (average) - 4.5 ºC (discharge)

• Emission scenarios:• LOWER HYPOTHESIS: IS92C • INTERMEDIATE HYPOTHESIS: IS92A • HIGH HYPOTHESIS: IS92E

• General circulation models: - UKTR - CCCEQ - hadcm2.

• Climatic sensitivities: - 1.5 ºc (decline) - 2.5 ºc (average) - 4.5 ºC (discharge)

• Emission scenarios:• LOWER HYPOTHESIS: IS92C • INTERMEDIATE HYPOTHESIS: IS92A • HIGH HYPOTHESIS: IS92E

STRATIFICATION OF THE BULTÓ INDEXSTRATIFICATION OF THE BULTÓ INDEX

• SI IB< -1.62• SI -1.61 <IB< -1.24• SI -1.23 <IB< -.64• SI -.63 <IB< .63• SI .64 <IB< .89• SI .90 <IB< 1.2• SI IB> 1.2

• SI IB< -1.62• SI -1.61 <IB< -1.24• SI -1.23 <IB< -.64• SI -.63 <IB< .63• SI .64 <IB< .89• SI .90 <IB< 1.2• SI IB> 1.2

• EXTREME COLD • VERY COLD• COLD WINTER• TRANSITE• WARM SUMMER• VERY WARM SUMMER• EXTREME SUMMER

• EXTREME COLD • VERY COLD• COLD WINTER• TRANSITE• WARM SUMMER• VERY WARM SUMMER• EXTREME SUMMER

ADAPTATION MEASURES ADAPTATION MEASURES

• To horizontalize the malaria control system. • To concentrate the malaria programs in the attention to the patient

concerning the diagnosis and treatment. • To strengthen the surveillance system, control and analysis of trends of

malaria. • To intensify the studies of vulnerability of malaria to the climate change. • To establish a monthly forecasting system of malaria in the endemic

departments. • To strengthen the epidemiological control of the people at bordering

countries.

• To horizontalize the malaria control system. • To concentrate the malaria programs in the attention to the patient

concerning the diagnosis and treatment. • To strengthen the surveillance system, control and analysis of trends of

malaria. • To intensify the studies of vulnerability of malaria to the climate change. • To establish a monthly forecasting system of malaria in the endemic

departments. • To strengthen the epidemiological control of the people at bordering

countries.

MONTHLY FORECASTING OF THE MALARIA CASES IN ALTO PARANÁ

MONTHLY FORECASTING OF THE MALARIA CASES IN ALTO PARANÁ

SISTEMA DE PRONOSTICO DE CASOS DE PALUDISMO EN ALTO PARANÁ

-50

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ENE FEB MAR ABR MAY JUN JUL AGO SEP OCT NOV DIC

• Malaria in Paraguay is in re-emergency. • Since 1999 the new world strategy was applied for its control. • The installed capacity for its control is vertical, still has not been

incorporation of the health services for its control and treatment. • Case persistence is observed in the areas of the indigenous corridor of

the more high endemicity departments. • There is no resistance demonstrated to chloroquine. • The radical scheme of 7 days is implemented. • Malaria is sensitive both to the variability and to the climate change.

Malaria is a disease that will suffer a great impact under conditions of climate change, according to the projections for 2010 should be produced a total increase of 82% with regard to the recorded cases before the 90s.

• Malaria in Paraguay is in re-emergency. • Since 1999 the new world strategy was applied for its control. • The installed capacity for its control is vertical, still has not been

incorporation of the health services for its control and treatment. • Case persistence is observed in the areas of the indigenous corridor of

the more high endemicity departments. • There is no resistance demonstrated to chloroquine. • The radical scheme of 7 days is implemented. • Malaria is sensitive both to the variability and to the climate change.

Malaria is a disease that will suffer a great impact under conditions of climate change, according to the projections for 2010 should be produced a total increase of 82% with regard to the recorded cases before the 90s.

CONCLUSIONSCONCLUSIONS

The use of the climatic forecast in the field of health not only requires a greater scientific comprehension of the system climate - health. It implies, in addition, a radical change in the way of thinking. It is necessary to find tools that take into account the various interactions that are given in this system, and that facilitate the integration of the climatic, ecological and epidemiological approaches, when evaluating the future behavior of the diseases.

The use of the climatic forecast in the field of health not only requires a greater scientific comprehension of the system climate - health. It implies, in addition, a radical change in the way of thinking. It is necessary to find tools that take into account the various interactions that are given in this system, and that facilitate the integration of the climatic, ecological and epidemiological approaches, when evaluating the future behavior of the diseases.

AcknowledgementsAcknowledgements

• To Dr. Keith Carter, Malaria Regional Adviser PAHO • To Lic. Blanca Cousiño, Technical Coordinator of SENEPA.• To Dr. Paulo Ortiz B. Adviser. Centro Nacional de Clima,

Cuba.

Thank You!!!

• To Dr. Keith Carter, Malaria Regional Adviser PAHO • To Lic. Blanca Cousiño, Technical Coordinator of SENEPA.• To Dr. Paulo Ortiz B. Adviser. Centro Nacional de Clima,

Cuba.

Thank You!!!