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Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor. PAHO Título de la presentación 1
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Jul 23, 2018

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Page 1: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

Malaria elimination in the Americas.

Challenges to the malaria elimination strategy

Dr. Roberto Montoya

Regional Malaria Advisor. PAHO

Título de la presentación1

Page 2: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

El Salvador

Number of malaria cases 1959 – 2015. El Salvador, Guatemala, Honduras and Nicaragua

Guatemala

Honduras Nicaragua

Cotton boom

DDT resistance

Civil wars

Programs changes

Page 3: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

Malaria cases 2015 and 1982

Subregion 1982 2015

Amazon 352,632 420,426

Central America 240,972 12,001

Hispaniola 70,008 18,244

Mexico 49,993 551

Southern Cone 633 9

Total 714,238 451,231

Page 4: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

Malaria en los países cerca de eliminación en la

Región de las Américas, 2013-2016

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Amazon countries :

• Suriname: few cases.

• Ecuador epidemiological situation changing but still favorable. Common issue: contention of reintroduction from neighbors?

• Bolivia without P. falciparum

• P. falciparum elimination as a intermediate target in Colombia, Brazil, Venezuela, Perú, Guyana

Southern cone :

zero indigenous cases in Argentina and Paraguay for more than 3 years. Both countries in certification processes

Mesoamerica : Possible as regional target. Three countries very close (Costa Rica, El Salvador, Belize). Two countries with favorable epidemiological situation (Mexico, Panama). Key local specific situations must be addressed (Guatemala, Honduras, Nicaragua)

Hispaniola : Possible as binational target. Critical gaps in access to diagnosis – treatment and vector control core interventions.MEC 2020: 7 countries

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Malaria morbidity Americas 2016

Page 7: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

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Page 8: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

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Cambio porcentual en morbilidad por malaria en comparación al año anterior 2010-2017: Mesoamérica

Datos preliminares para el año 2017

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Cambio porcentual en morbilidad por malaria en comparación al año anterior 2010-2017: Sudamerica

Datos preliminares para el año 2017, Proyección usada para Venezuela (2017)

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Page 12: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

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Malaria morbidity in Venezuela. 2000 – 2016.

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Malaria in Bolivar State, Venezuela

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Malaria morbidity in Colombia. 2000 – 2016.

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Number of malaria cases Brazil. 2016 - 2017

Título de la presentación

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Malaria incidence. Peru, 2016

Título de la presentación

Page 17: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

Malaria elimination in the Americas.

Challenges to the malaria elimination strategy

Dr. Roberto Montoya

Regional Malaria Advisor. PAHO

Título de la presentación17

Page 18: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.
Page 19: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

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The programme actions along the continuum of malaria transmission, from

high to very low

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Drivers of malaria risk in the Region

• Gold mining operations (large scale driver)

• Agricultural activities and investments (banana, sugar, oil palm)

• Intensification of other economical activities (fishing – jellyfish, sea

cucumber, Brazil nuts)

• Migrations (labor)

• Land conflicts, illegal activities, and rural to urban migrations

Título de la presentación

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Correlation between annual parasite index (API) and gold-mining district (GMD) production

31.6% of malaria cases were from mining areas.

The annual parasite index (API) correlated with gold production (R2 0.82, p < 0.0001);

… for every 100 kg of gold produced, the API increased by 0.54 cases per 1,000 inhabitants

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Gold mining and malaria

Título de la presentación

• Increases the size of dispersed settlements

• Increase breeding niches for the Anopheles mosquito

• Exposure of immunologically naive persons to infection

• Increase in malaria transmission

• Poor housing conditions

• Mobile population

• Poor access to health services

• Illegal conditions and connection with other illegal activities (more barriers to access

services)

• Counterfeit medicines, black market, monotherapy, incomplete treatmets and self-

medication

• Migration (risk for spread of malaria transmision and resistant parasites)

• Malaria .. the tip of the iceberg (social and public health problem)

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Page 25: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

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Challenges for malaria elimination

• Eliminate P. falciparum before emergence of resistance to ACT

• Relapses

• Other challenges related with P. vivax (gametocites day 0)

• Exophagic vectors with exophilic resting behavior

• Undetected infections

• Socio - economic drivers

• Porous borders and intense intra / inter-country migration

• Hard to reach populations

• Changes in malaria and other vector borne diseases programs

• Gaps in primary health care models in rural areas

Título de la presentación

Page 26: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

Closing Local Gaps Toward Malaria Elimination

Page 27: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

How to eliminate malaria?...

Malaria elimination at country level is the sum of the elimination of malaria in each one of the foci

The work must be done at local level (municipality, focus)

… transforming all active foci into cleared foci

Page 28: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

How to eliminate malaria?...

• By early infection detection and radical treatment

• Infection detection is a technical / operational bottle neck to eliminate the human reservoir

• How much early? How much sensitive? How much massive?

------------------------------------------------------------------------------------------

• There are still important gaps in infection detection (mainlysymtomatic malaria) that can be addressed improving access to RDT and microscopy

• Access to diagnosis as the key operational bottle neck towards elimination of human reservoir

• But, access to treatment also remains as basic operational bottle neck

… eliminating the human reservoir of parasites

Page 29: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

Closing Local Gaps Toward Malaria Elimination: two key ideas

Concentrate efforts in closing gaps in key interventions ( dti-r)

Promote joint efforts in key municipalities (foci): “high burden” and “eliminating”

1

2

Page 30: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

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?

Hu

man

res

erv

oir

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• Countries with massive efforts in detection but without proper diagnosis (no prompt

case investigation and response)

• Countries with short time for detection but critical delays in diagnosis (case

investigation and response)

• Territories where RDT should be highly effective but with important gaps in

implementation

• Areas with legal restrictions for diagnosis and treatment by community health

workers

• Countries with barriers for accessing diagnosis even in urban areas

• Countries with community health workers being considered in the malaria strategy

but without appropriate networking support and structure

• Countries where community health workers are not even considered in the new

health model

• Countries where diagnosis is only available at the central level

Título de la presentación

Access to prompt diagnosis is the main gap

Page 32: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

DIAGNOSIS

Every suspected

malaria case must

be diagnosed using

microscopy or RDT

within the first 48h

from onset of

symptoms. In low

transmission

settings:

unrealistic? Always

in the first 7 days

from onset of

symptoms.

TREATMENT

Every confirmed

case must receive

appropriate

treatment based on

the national

protocols, starting

the same day of the

diagnosis.

INVESTIGATION

Every case or

cluster of cases

should trigger a

basic action to

promptly detect and

treat other possible

related cases within

7 days.

7 days from the onset of symptoms

d t i

Gaps ? Gaps ? Gaps ?

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• dti-r is a stepwise approach in which diagnosis, with the consequenttreatment, is the first step,

• Investigation, surveillance and response are the natural extension of aproper network of diagnosis.

Without proper diagnosis, there is no propertreatment, no investigation, no knowledge of malariadistribution, no way to stratify the risk, no way toidentified focus, no guidance for vector control, noresponse.

• Assuming that dti-r is the anchor of a successful program, attention shouldbe focused on coverage, access and quality of the services.

Título de la presentación

Page 34: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

Closing Local Gaps Toward Malaria Elimination: two key ideas

Concentrate efforts in closing gaps in key interventions ( dti-r)

Promote joint efforts in key municipalities (foci): “high burden” and “eliminating”

1

2

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15 municipalities in 2015 contributed more that 80% of the cases of the continent:

Page 36: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

• Malaria transmission in Americas is geographically heterogeneous.

•• Malaria transmission is concentrated in limited number of municipalities

• Within high burden municipalities there is also an important geographical heterogeneity in malaria transmission: key foci

• Malaria transmission in key foci may influence malaria transmission across the country… and across countries (Mesoamerica)

• The most efficient way to eliminate (and to reduce) malaria is to work on the “high burden” foci

Page 37: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

Título de la presentación37

Identifying barriers and gaps …

• Diagnosis• Treatment• Investigation• Response

How to address the focus - MethodologyDynamics of malaria transmission- analysis / hypothesis

Identifying local drivers of the transmission,

1

2

Page 38: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

Call for action for national and local authorities and other actors to increase efforts in reducing burden and eliminating malaria in “high burden” municipalities

Page 39: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

Título de la presentación39

Technical missions Assessments of the malaria situation

Expert consultations

Task forces (for key foci)

Advocacy with authorities

Local plans for malaria elimination

Legal and normative barriers

Public – private partnership

Networking

Communities of practice

South – south cooperation

Pilot experiences – (the foci as pilot areas)

Training in service

Scenario for academic training programs

Operational research (foci level)

Innovation (technological and operational)

Communication

Call for action for national and local authorities and other actors to increase efforts in reducing burden and eliminating malaria in “high burden” municipalities

Page 40: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

Thank you

Page 41: Malaria elimination in the Americas. - ghc.fiu.edu · Malaria elimination in the Americas. Challenges to the malaria elimination strategy Dr. Roberto Montoya Regional Malaria Advisor.

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