3

Bolivia

Overview of the situation Figures 1-5

In Bolivia, malaria is endemic in two main areas - in the north and in the south of the country. Malaria transmission is most intense in the Amazon Departments of Beni and Pando, which border Brazil and Peru. Plasmodium falciparumborne malaria is highly focal in this region of the country, where transmission peaks are associated with the harvesting activities in which a large part of the population is engaged. The perpetuation of malaria transmission can be traced to the difficulties in timely access to health services and poor living conditions of the population groups that move around to harvest Brazil nuts in those regions. In 2008, 9,748 cases of malaria were reported in Bolivia, of which 836 were P. falciparum -borne, making it the country with the smallest percentage of transmission by P. falciparum in the Amazon region. The Department of Beni reported 5,826 cases (59%), most of them in people involved in carrying out harvesting activities in the adjacent Department of Pando. As in the rest of the Amazon region of the neighboring countries, Anopheles darlingi is the principal species of malaria vector. As part of the vector control activities, entomological studies were recently conducted in areas of high malaria transmission in the Departments of Beni and Pando; mosqui70

to biting rates were found between 1.2 and 242 bites per night inside dwellings. The Municipality of Guayaramerin, adjacent to the border with the Brazilian State of Rondonia, has the second highest number of cases and is an important urban malaria transmission area. In southern Bolivia, on the border with Argentina and Paraguay, malaria is concentrated in a few pockets in the Department of Tarija, where Plasmodium vivax-borne malaria predominates. In this region, Yacuiba reported 858 cases in 2008, making it the country’s third-highest municipality in malaria incidence. In localities of this region with less intensive malaria transmission, Anopheles pseudopunctipenis is the responsible vector species.

Morbidity and mortality trends Figures 4 – 9

Malaria transmission in Bolivia has dropped considerably over the past 10 years. P. vivaxborne malaria was 30.6% lower in 2008 than the previous year, while the drop in P. falciparum transmission is almost 50% in the same period. The 9,748 cases reported in 2008 constitute the lowest figure since the 1998 epidemic, when 74,350 cases were reported. There have been no reported deaths from malaria in the country since 2003.

R e por t o n t h e S i t uat i o n o f M a l ar i a i n t h e A m e r i c as , 2 0 0 8

R e por t o n t h e S i t uat i o n o f M a l ar i a i n t h e A m e r i c as , 2 0 0 8

Geographical distribution Figures 1, 12 – 19

The Municipality of Riberalta, in the Department of Beni, with 3,620 cases reported in 2008, accounts for 38.4% of the country’s total malaria cases. This municipality along with the municipality of Guayaramerin accounted for 60% of Bolivia’s malaria morbidity. This shows a high concentration of malaria cases in this region, which could offer a good opportunity for control efforts. While malaria transmission was found to exist in 66 municipalities in 2008, 19 of these reported less than 5 cases each, while 17 had more than 50. Only 13 municipalities reported 1 or more cases of P.falciparum-borne malaria and only 3 reported more than 10 cases transmitted by this parasite species during the period. Bolivia’s malaria situation is better than that of its neighbors. Given its highly focal transmission, high impact operations can be expected to be successful in the short term. In 2006, the malaria program, which had previously used the total populations of malariaendemic municipalities, adjusted the population at risk. Even so, Annual Parasite Incidence (API) dropped, particularly in the high-risk municipalities. Furthermore, the number of malaria-endemic municipalities gradually decreased, from 150 in 2005 to 66 in 2008.

Malaria in priority groups Figures 25 – 28

In 2008, 9.4% of the malaria cases reported in Bolivia were among children under the age of 5. Malaria transmission in urban areas, namely the municipality of Guayaramerin, in the Department of Pando, accounted for 11% of the total cases.

B O LI V I A

Although the malaria information system does not record the ethnic origin of the cases, because of Bolivia’s demographic characteristics, most of these are considered indigenous. This is especially obvious among the Brazil nut harvesters in the Departments of Beni and Pando, where over 60% of the cases are reported. The individual reporting-based information system under implementation since 2007 made it possible to determine that in 2008, 6.3% of the cases of malaria among women of childbearing age in the Departments of Beni and Pando were in pregnant women. Inasmuch as the general fertility rate in Bolivia is close to 110 per 1,000 (11%), the reported percentage of pregnant women with malaria could mean that a sizeable number of such women with malaria are not being reported as being pregnant and are possibly not receiving the special care they need.

Diagnosis and treatment Figures 20 – 24, 29 – 30

In 2008, the malaria program conducted 159,826 slides were examined in suspected cases with access to the health system. The SPR was 6.1%, lowest since 2000. Although the SPR in the Department of Beni, where most of the malaria cases are concentrated, was higher than that of other departments, it was lower than that reported in areas with higher levels of malaria transmission in other countries of the region, like Brazil and Colombia. In 2008, 48% of the malaria cases were diagnosed within the first 72 hours after the onset of symptoms. Late initiation of treatment in a large number of cases is apparently a determining factor in continued malaria transmission in the most endemic areas.

71

72

B O LI V I A

R e por t o n t h e S i t uat i o n o f M a l ar i a i n t h e A m e r i c as , 2 0 0 8

In 2005, Bolivia started to use RDTs for malaria diagnosis and in 2008, 5,000 tests were used, amounting to 3% of all suspected cases examined. Timely access to parasitological diagnostic test for malaria is impossible in difficult-to-reach scattered areas. Although no objective information exists about cases of fever among people who have no contact with the health system, their existence can be assumed in several malaria endemic areas, particularly in the Amazon region. Bolivia was the second country in the region to introduce the use of ACTs for malaria treatment. The country has been using the ASU+MQ combination since 2001 as a first-line therapy for uncomplicated P. falciparum malaria. The introduction of ACT treatment in 2001 coincided with a marked decline in the number and percentage of P. falciparum malaria cases. However, despite the continued use of ACTs, the proportion of P. falciparum malaria rose between 2005 and 2007, dropping once again in 2008.

Prevention and vector control Figures 31-33

While IRS continues to be one of the vector control strategies in Bolivia, its use declined simultaneously with the drop in the number of malaria cases between 2005 and 2008. The number of people protected by IRS in 2008 was almost 6 times smaller than in 2005; it should be noted, however, that over the past three years, a total of approximately 60,000 persons have been protected by LLINs, close in number to the total people protected by IRS in 2005, when malaria episodes in the country surpassed 20,000.

The widest coverage through the use of LLINs introduced in Bolivia in 2005, was reached in 2006, during the implementation of the project financed by the Global Fund. In 2007, with support from the USAID-funded AMI Initiative, the LLIN implementation strategy was launched in selected localities, with the adoption of a package of operating requirements focused on achieving good usage coverage in the localities benefited and appropriate handling to safeguard duration. In 2008, 5,000 LLINs were distributed.

Financing of malaria control Figure 34

Between 2004 and 2006, Bolivia benefited from a malaria control project financed by the Global Fund. The financing was suspended in 2007 and a second project submitted during the 8th convocation of the GFATM was approved in 2008.

B O LI V I A

R e por t o n t h e S i t uat i o n o f M a l ar i a i n t h e A m e r i c as , 2 0 0 8

Figure 1. Number of cases by ADM 2 level (municipality, district), 2008

Legend P. falciparum

1 Dot = 10 cases P. vivax

Brazil

1 - 73 74 - 216 217 - 315 316 - 1170 1171 - 4890 Peru

No cases

Bolivia

Chile Paraguay

Argentina

Figure 2. Proportion of cases by species, 2008

9%

91%

Plasmodium species P. vivax P. falciparum and mixed

3

73

B O LI V I A

R e por t o n t h e S i t uat i o n o f M a l ar i a i n t h e A m e r i c as , 2 0 0 8

Figure 3. Number of malaria cases by species by ADM1 level in 2008 P. falciparum + mixed

P. vivax

Total cases

Beni

726

5,100

5,826

Beni

Tarija

0

1,424

1,424

Tarija

Santa Cruz

24

889

913

Santa Cruz

Pando

70

730

800

Pando

Cochabamba

3

247

250

Cochabamba

La paz

13

234

247

La paz

Potosi

0

156

156

Potosi

Chuquisaca

0

132

132

Chuquisaca

ADM1

ADM1

0

Plasmodium species

2,000 4,000 6,000 0% 50% 100% Total number of cases Percentage of total cases

P. vivax

Figure 5. Number of malaria cases, 2000 - 2008

Figure 4. Number of cases by species, 2000 - 2008 40,000

30,000 28,932

31,469

P. falciparum and mixed

2,446 808

0

727

793

695

1,080

1,785

1,610

18,995

20,142

10,000

8,912 836

0

9,748

12,988

14,610

13,549

10,000

20,000

14,910

14,215

20,343

17,210 14,957

14,276

19,062

17,319

15,765

20,000

Number of cases

30,000

2000 2001 2002 2003 2004 2005 2006 2007 2008

2000 2001 2002 2003 2004 2005 2006 2007 2008

Year

Year

Plasmodium species P. falciparum and mixed

P. vivax

Figure 6. Number of malaria deaths, 2000-2008 4

4

4

Figure 7. Number of hospitalized malaria cases, 2000 - 2008

4

300

3 2

Number of cases

Number of deaths

74

2

1 0

0

0

0

0

200 100

82 44

0

2000 2001 2002 2003 2004 2005 2006 2007 2008 Year

285

0

NA

NA

0

6

0

0

2000 2001 2002 2003 2004 2005 2006 2007 2008 Year NA - No Data Available

B O LI V I A

R e por t o n t h e S i t uat i o n o f M a l ar i a i n t h e A m e r i c as , 2 0 0 8

Figure 8. Annual variations in number of cases 4,847

3,770

-1,638

-175

-98

-1,408

-1,852

-3,104

-5,000

0%

705

385

66

-81

0

0%

-774

-4,222 -4,076

-10,000

Percentage difference

Difference in number of cases

500

Figure 9. Percentage difference in number of cases compared to 2000

-20% -27% -34%

-40%

-48%

-40% -53%

-60%

-56% -70%

2000 2001 2002 2003 2004 2005 2006 2007 2008

-51%

-67%

-13,975

-68%

-80%

-34% -41% -55%

-72%

Year

Plasmodium species P. falciparum and mixed

P. vivax

Plasmodium species P. falciparum and mixed

Figure 11. Percentage of hospitalized cases, 2008

Figure 10. Number of cases and RBM / MDG targets for 2010 and 2015

0%

30,000

20,000

10,000 2015

2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

100% 2000

Number of cases

-69%

2000 2001 2002 2003 2004 2005 2006 2007 2008

Year

Percentage of cases

Year Reported cases

-66%

RBM / MDG Targets

Oupatients Hospitalized

P. vivax

75

B O LI V I A

R e por t o n t h e S i t uat i o n o f M a l ar i a i n t h e A m e r i c as , 2 0 0 8

Figure 12. Districts (ADM2) with highest malaria burden and cummulative proportion of total cases in the country, 2008 Riberalta

3,620

Guayaramerin

38%

1,994

Yacuiba

60%

858

San Ignacio de Velasco

327

Bermejo

312

El Torno

306

69% 72% 75% 79%

Villa Tunari

215

Buena Vista

186

San Lorenzo (Exaltación)

156

85%

Bolivar (Sena)

139

86%

Baures

116

87%

Carapari

106

88%

Nueva Esperanza (Nuevo M.)

102

90%

Toro Toro

85

90%

Villamontes

79

91%

Victoria (Puerto Rico)

70

92%

Ayata

53 0

81% 83%

93% 1,000

2,000

3,000

4,000 0%

Number of cases

20%

40%

60%

80%

100%

Cummulative proportion (%) of total cases

* See Annex A for a complete list.

Figure 13. Districts (ADM2) by number of malaria cases, 2008

501-1,000

Figure 14. Districts (ADM2) by number of P. falciparum cases, 2008 Number of

Number of cases >1,001

P. falciparum cases

2 1

251-500

3

101-250

251-500

1

101-250

1

11-50

1

7

51-100

6-10

4

11-50

7

Grand Total

7

1-5

3

1-5

23

6-10

13 0

19

2

4

Grand Total

6

8

10

12

14

Number of districts 0

10

20

30

40

50

60

70

Number of districts

Figure 15. Districts (ADM2) by number of cases, API and percentage of P. falciparum cases, 2008 API

250

25 Percentage of P. falciparum cases

76

25

0.05 20

20

40

Santos Mercado (Eureka)

60 80

15

105.15

Ixiamas Riberalta Guayaramerin

Bella Flor (Costa Rica) 10 Villa Nueva (Loma Alta) 5

Bolivar (Sena)

Santa Rosa del Abuna (Nacebe) 0

ZudanezAcasio 2

5

Ayata 10

20

50

Yacuiba

Baures 100

200

Number of cases (logarithmic scale)

500

1,000

2,000

5,000

B O LI V I A

R e por t o n t h e S i t uat i o n o f M a l ar i a i n t h e A m e r i c as , 2 0 0 8

Figure 16. Annual Parasite Index (API) by districts (ADM2), 2008

Legend Municipal API

0.01 - 1.00 1.01 - 5.00

Brazil

5.01 - 10.00 10.01 - 50.00 50.01 - 100.00 100.01 - 500.00

Peru

Bolivia

Chile Paraguay

Argentina

Figure 17. Population by malaria transmission risk, 2008

2% 5% 7%

86%

Population High risk (API > 10/1000) Medium risk (1/1000 < API < 10/1000) Low risk (API < 1/1000 ) Malaria free areas (No indigenous transmission)

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78

B O LI V I A

R e por t o n t h e S i t uat i o n o f M a l ar i a i n t h e A m e r i c as , 2 0 0 8

Figure 19. Population by malaria transmission risk, 2000-08

Figure 18. Annual Parasite Index (API) and number of cases by district*, 2008

Year

Nueva Esperanza (Nuevo)

102

Bolivar (Sena)

139

105.15

3,620 156

Malaria free areas (No indigenous transmission)

44.33

2000

742,000

2,828,000

0

4,857,790

42.67

2001

337,000

1,434,000

100,000

6,753,268

41.01

2002

294,000

666,000

2,377,000

5,486,743

38.83

2003

1,429,000

339,000

1,544,000

5,712,922

36.32

2004

427,000

461,000

2,482,000

5,856,511

1,994 53

Riberalta San Lorenzo (Exaltacion)

Low risk (API < 1/1000)

55.87

Guayaramerin Ayata

Medium risk (1/1000 < API < 10/1000)

High risk (API > 10/1000)

Santos Mercado (Eureka)

28

Villa Nueva (Loma Alta)

35

29.89

2005

368,000

423,000

2,887,000

5,749,219

Ravelo (Moro Moro)

36

28.57

2006

271,000

438,000

720,000

8,198,269

Gral. Juan Jose Perez

23

27.06

2007

271,388

438,495

849,532

8,268,107

Baures

116

2008

188,804

516,248

678,535

8,644,057

Victoria (Puerto Rico)

70

22.02 15.35

Toro Toro

85

14.04

Ingavi (Humaita)

12

13.19

Buena Vista Villa Serrano

186

12.82

16

10.7

Carapari

106

10.61

Bella Flor (Costa Rica)

23

10

Acasio

7

9.03

Santa Rosa del Abuna

23

8.97

Bermejo

312

8.03

San Ignacio de Velasco

327

6.99

Yacuiba Azurduy

858

6.82

37

El Torno

6.69

306

6.36

Teoponte

26

6.19

Agua Dulce (Pto. G. More)

29

6.15

Zudanez

4

6.02

Ixiamas

45

5.81

Porvenir (Campo Ana)

23

5.36

Villa Tunari

215

Year

Number of slides examined

Number of slides positive

Slide Positivity Rate (%)

2000

143,990

31,469

21.85

2001

122,933

15,765

12.82

2002

137,509

14,276

10.38

2003

158,299

20,343

12.85

2004

163,307

14,910

9.13

2005

202,021

20,142

9.97

2006

208,616

18,995

9.11

2007

180,316

14,610

8.05

2008

159,826

9,748

6.1

4.38

Padcaya

24

3.69

Padilla

21

3.35

0

Figure 20. Slides examined and Slide Positivity Rate (SPR), 2000-2008

2,000

4,000

Number of cases

0

50

100

150

API

Figure 21. Cases diagnosed by microscopy and RDTs, 2000-08

API (cases/ 1000 people at risk) 0

105.15

Diagnostic Method * See Annex A for a complete list

Year 2000 2001 2002 2003 2004 2005 2006 2007 2008

Microscopy

RDTs

143,990 122,933 137,509 158,299 163,307 202,021 6,000 208,616 6,000 180,316 159,826 5,000 0

100,000

200,000

Number of cases

0

100,000

200,000

Number of cases

B O LI V I A

R e por t o n t h e S i t uat i o n o f M a l ar i a i n t h e A m e r i c as , 2 0 0 8

Figure 23. Slide Positivity Rate (SPR) by ADM1, 2008

Figure 22. Number of cases diagnosed and cases treated, 2000-2008 ADM1

Year 2000

Diagnosed cases Cases treated Diagnosed cases Cases treated

2001

Diagnosed cases Cases treated

2002

Diagnosed cases

2003

Cases treated Diagnosed cases Diagnosed cases Cases treated

2005

Diagnosed cases Cases treated

2006

Diagnosed cases

2007

Cases treated Diagnosed cases

2008

Cases treated Diagnosed cases

Total cases

65,694 36,375 25,914 18,393 1,729 4,121

5,826 1,424 913 800 250 247

8.87 3.91 3.52 4.35 14.46 5.99

1,998 5,602 ---

156 132 0

7.81 2.36 0

Potosi Chuquisaca Oruro

Cases treated

2004

Examined

Beni Tarija Santa Cruz Pando Cochabamba La paz

SPR (%)

--- Data not available

Figure 25. Number and percentage of cases by age group, 2008

Cases treated

0

10,000

20,000

30,000

Number of cases diagnosed/treated

50

9.4% 26.4% 54.9% 9.3% 0

2,000

4,000

Number of cases

Figure 24. Time span between onset of symptoms and diagnosis, 2008

Figure 26. Number and percentage of cases by locality type, 2008 52%

Urban Rural

11.0% 89.0% 0

2,000

4,000

6,000

8,000

Number of cases

Figure 27. Number and percentage of cases in pregnant women among women of child bearing age, 2008

48%

Time span between onset of symptoms and diagnosis

Pregnant Not pregnant

6.3% 93.7% 0

>72 hours

500

1000

1500

Number of cases