El Salvador - Global Health Sciences

COUNTRY BRIEFING
Eliminating malaria in
EL SALVADOR
El Salvador reported only 24 cases of malaria in 2010 and is working to enhance
its surveillance system to quickly identify and control imported cases.
Overview
At a Glance
1
24 Reported cases of malaria
(92% P. vivax)
0
Deaths from malaria
83 % of population at risk
(total population: 6.1 million)
0.003
Annual parasite incidence
(cases/1,000 total population/year)
0.02
% Slide positivity rate
Source: World Health Organization, World Malaria Report 2011
Malaria Transmission Limits
Plasmodium vivax
El Salvador reduced its malaria burden by 99 percent between
1990 and 2010, and is categorized in the pre-elimination
phase by the World Health Organization (WHO).1 The last
reported death from malaria occurred in 1984.2
Plasmodium vivax is the predominant malaria parasite,
and since 2001 there have been only 14 reported cases of
P. falciparum.1 From 2004 to 2007, more than 40 percent of
all cases were imported, and 91 percent of imported cases in
2008 occurred in people between the ages of 15 and 44 who
migrated to El Salvador for agricultural or artisanal work.3
Anopheles albimanus is the primary vector; malaria transmission occurs year-round but peaks during the rainy season
from May to October.4, 5
Although El Salvador now maintains low transmission with
relatively few reported cases, the scattered transmission foci
requires a dispersed concentration of malaria activities. San
Salvador Province in the central part of the country contains
nearly one-third of El Salvador’s population and had 42 percent of all reported malaria cases in 2008.3 Cases were also
reported throughout the southwest region along the border
with Guatemala, including in the provinces of Ahuachapán,
Santa Ana, and Sonsonate, and in the province of La Uniòn
along the eastern border with Honduras.
Water
P. vivax free
Unstable transmission (API <0.1)
Low stable transmission (0.1≥ API <1.0)
Stable transmission (≥1.0 API)
0
MAY 2012
50
100
150 Kilometres
P. vivax malaria risk is classified into no risk, unstable risk of <0.1 case per
1,000 population (API), low stable risk of ≥0.1 to <1.0 case per 1,000 population (API), and stable risk of ≥1.0 case per 1,000 population (API). Risk
was defined using health management information system data and the
transmission limits were further refined using temperature and aridity data.
Data from the international travel and health guidelines (ITHG) were used
to identify zero risk in certain cities, islands and other administrative areas.
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COUNTRY BRIEFING
Eliminating malaria in EL SALVADOR
El Salvador has plans to improve microscopy practices,
implement community-driven practices, increase epidemiological surveillance, reduce transmission foci, and control the
number of imported malaria cases.3 Furthermore, the malaria
program conducts active case detection in areas where
temporary employment is found, such as handmade brick
and tile factories, plantation estates, and mills. Nearly US$2
million was provided for malaria control in 2008, all of which
came from the government.3 With continued support from
the government and targeting high-risk-areas by the program, El Salvador is in a good position to eliminate malaria.
Progress Toward Elimination
In the 1960s, El Salvador averaged more than 160,000 cases
of malaria each year, of which 60 percent were P. vivax and
40 percent were P. falciparum.5 To reduce this high caseload,
El Salvador implemented mass drug administration and
widespread use of indoor residual spraying with DDT. While
reductions in mortality and morbidity were achieved, by the
1970s insecticide resistance appeared and spraying with
DDT was scaled back.6 During this same period, the cotton
industry expanded greatly, causing extensive deforestation,
thereby increasing mosquito breeding habitats.6 Seasonal
workers from the low-risk highland regions of El Salvador
migrated to the high-risk Pacific coastal plains for work and
were more susceptible to contracting malaria because of
their low levels of malaria immunity, poor housing structures,
and limited access to health services.6
The Salvadoran Civil War broke out in 1980, causing a near
standstill in health services, industry, and malaria control
efforts. The cotton industry collapsed, and seasonal worker
migration no longer posed a significant role in malaria transmission.6 The war presented a challenge to malaria control
surveillance and vector control; the quality and availability of
health services deteriorated and environmental degradation
resulting from misuse of land greatly increased the presence
of vectors.7 In 1992, the armed conflict ended and thousands
of refugees and ex-combatants settled in agricultural communities as part of the national land transfer program; however, most of the land had been deforested during the war.
Over the next few years, the malaria program was strengthened, including a new focus on surveillance, vector control,
and an increased government role in managing malaria—all
of which contributed to a steady decline in cases.3, 8 However,
an outbreak occurred in 1996, most likely due to the continuation of poor land management by agricultural industries; it
was quickly brought under control and cases declined.1, 9
Reported Malaria Cases
10,000
Number of cases
9,000
8,000
7,000
6,000
5,000
4,000
3,000
2,000
117
85
112 67
49
40
33
20
24
cases cases cases cases cases cases cases cases cases
1,000
0
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
The number of cases of malaria in El Salvador has been consistently declining over the past two decades, except for an
outbreak in 1996.
Source: World Health Organization, World Malaria Report 2011
MAY 2012
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COUNTRY BRIEFING
Eliminating malaria in EL SALVADOR
Since 2003, in coordination with the Pan American Health
Organization (PAHO),10 El Salvador moved away from DDT
use and employed alternative malaria control methods such
as planting neem trees, which are attributed to playing a
role in the declining number of malaria cases due to their
antimalarial properties.3, 11 The ministry of health increased
funding in 2007 to strengthen the monitoring and control
of vector-borne diseases and deliver equipment for thermal
fogging and microscopes for malaria surveillance and case
management.12 Additionally, the ministry of health published a manual outlining the technical guidelines for proper
microscopic diagnosis of malaria and developed certification
criteria for malaria-free zones.13
El Salvador reported an extremely low malaria burden in 2010;
however, 83 percent of the population is still considered at
risk due to the widespread prevalence of the vector and scattered transmission foci.3 Malaria control success has been attributed to: strong human resources; good program management; strong microscopy skills in affected areas; public and
private sector collaboration; and large groups of organized
community volunteers equipped with malaria testing kits.14
Geographic information system mapping software is currently
being implemented to strengthen malaria surveillance and
help El Salvador reach national malaria elimination.2
Challenges to Eliminating
Malaria
Migrant populations
El Salvador’s greatest challenge to controlling malaria is managing the threat of malaria importation. Many immigrants
from neighboring countries cross into El Salvador in search
of employment. In 2007, there were many Nicaraguans and
Hondurans living in El Salvador, and even more temporary
immigrant workers who came looking for work in the sugar
industry.19 To address this challenge, El Salvador is partnering
with PAHO to increase cross-border cooperation with Honduras and Nicaragua.19
Conclusion
El Salvador has made remarkable progress in reducing its
malaria burden and is now close to elimination. The ministry
of health is continuing to work with PAHO to develop innovative strategies for malaria elimination, including cross-border
collaboration, transmission foci reduction, and engaging
at-risk communities in malaria surveillance and control.
Eligibility for External Funding15–17
The Global Fund to Fight AIDS, Tuberculosis and
Malaria
Yes
U.S. Government’s President’s Malaria Initiative
No
World Bank International Development Association
No
Economic Indicators18
GNI per capita (US$)
$3,380
Country income classification
Lower middle
Total health expenditure per capita (US$)
$237
Total expenditure on health as % of GDP
7
Private health expenditure as % total
health expenditure
38
MAY 2012
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COUNTRY BRIEFING
Eliminating malaria in EL SALVADOR
Sources
1. WHO. World Malaria Report 2011. Geneva: World Health Organization; 2011.
2. Ministerio de Salud – El Salvador. Proyecto DDT/GEF. Qunta Reunion del Comite Directivo. Mexico DF; 2008.
3. PAHO. El Salvador – Informe de la Situacion del Paludismo en las Americas. 2008.
4. Sinka ME, Rubio-Palis Y, Manguin S, Patil AP, Temperley WH, Gething PW, et al. The dominant Anopheles vectors of human malaria in the
Americas: occurrence data, distribution maps and bionomic precis. Parasit Vectors 2010; 3:72.
5. Rachou RG, Lyons G, Moura-Lima M, Kerr JA. Synoptic Epidemiological Studies of Malaria in El Salvador. Am J Trop Med Hyg 1965; 14: 1–62.
6. Packard RM. The Making of a Tropical Disease: A Short History of Malaria: The Johns Hopkins University Press; 2007.
7. Ugalde A. The health costs of war: can they be measured? Lessons from El Salvador. BMJ 2000; 321 (169).
8. Vargas A. El Salvador Country Brief: Property Rights and Land Markets. Madison: Land Tenure Center - University of Wisconsin; 2003.
9. A. Nájera. Malaria Epidemics Detection and Control Forecasting and Prevention: World Health Organization; 1998.
10. UNEP/WHO/GEF. Countries move toward more sustainable ways to roll back malaria WHO. 2009.
11. PAHO. Lanzamiento del Árbol NIM en el Municipio de Santo Tomás 2008 [cited 2010 3 March 2010]; Available from: http://devserver.paho.
org/els/index.php?option=com_content&task=view&id=67&Itemid=216&lang=en.
12. Ministero de Salud – El Salvador. Ministro de Salud hace entrega de importante equipo para la prevención del Dengue y la Malaria: a
personal del Ministerio de Salud. San Salvador; 2007.
13. Ministero de Salud – El Salvador. Manual de Procedimientos Tecnicos Para El Diagnostico Microscopico de la Malaria; 2007.
14. WHO. Informal consultation on malaria elimination: setting up the WHO agenda. World Health Organization Global Malaria Programme; 2006.
15. IDA. International Development Association Eligibility. 2012; Available from: http://web.worldbank.org/WBSITE/EXTERNAL/EXTABOUTUS/IDA/0,,contentMDK:20054572~menuPK:3414210~pagePK:51236175~piPK:437394~theSitePK:73154,00.html.
16. PMI. U.S. Government’s President’s Malaria Initiative (PMI). 2012; Available from: http://www.fightingmalaria.gov/countries/index.html
17. The Global Fund to Fight AIDS Tuberculosis and Malaria. The Global Fund Eligibility List. 2012; Available from: http://www.theglobalfund.
org/en/application/applying/ecfp/eligibility.
18. World Bank. World Development Indicators Database. 2012; Available from: http://data.worldbank.org.
19. Migration Information Source. El Salvador: Despite End to Civil War, Emigration Continues, 2007. Available from: http://www.migrationinformation.org/Profiles/display.cfm?ID=636.
Transmission Limits Map Sources
Guerra, CA, Howes, RE, Patil, AP, Gething, PW, Van Boeckel, TP, Temperley, WH, Kabaria, CW, Tatem, AJ, Manh, BH, Elyazar, IRF, Baird, JK,
Snow, RW and Hay, SI. (2010). The international limits and population at risk of Plasmodium vivax transmission in 2009. Public Library of
Science Neglected Tropical Diseases, 4(8): e774.
Status of malaria in the Americas, 1994–2007: a series of data tables, World Health Organization/Pan American Health Organization (Regional
Office for the Americas), Washington D.C., United States of America, URL: http://www.paho.org/English/AD/DPC/CD/mal-americas-2007.pdf
(Data year 2006)
MAY 2012
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COUNTRY BRIEFING
Eliminating malaria in EL SALVADOR
About This Briefing
This country briefing was produced through a collaboration of the Global Health Group, in partnership with the National Malaria
Control Program in El Salvador. Malaria transmission risk maps were provided by the Malaria Atlas Project (MAP). Funding was
provided through a grant to the Global Health Group from the Exxon Mobil Corporation.
The Malaria Elimination Initiative at the Global Health Group of the
University of California, San Francisco (www.globalhealthsciences.ucsf.
edu/global-health-group) convenes the Malaria Elimination Group
(www.malariaeliminationgroup.org), and supports countries actively
pursuing elimination at the endemic margins of the disease. Funding
for the Malaria Elimination Initiative is provided by the Bill & Melinda
Gates Foundation and Exxon Mobil Corporation.
The Malaria Atlas Project (MAP) provided the malaria transmission
maps. MAP is committed to disseminating information on malaria risk,
in partnership with malaria endemic countries, to guide malaria control
and elimination globally. Find MAP online at: www.map.ox.ac.uk.
GlobAL Health Group Project Team
Editor: Allison Phillips | Managing Editor: Chris Cotter | Researcher and Content Developer: Janelle Downing | Graphic Designer: Kerstin Svendsen
MAY 2012
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