bolivia3

Overview of the situationFigures 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 falciparum-borne malaria is highly focal in this region of the country, where transmission peaks are associa-ted with the harvesting activities in which a large part of the population is engaged. The perpetua-tion 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 repor-ted 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 re-ported 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 coun-tries, 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; mosqui-

to biting rates were found between 1.2 and 242 bites per night inside dwellings. The Municipali-ty of Guayaramerin, adjacent to the border with the Brazilian State of Rondonia, has the second highest number of cases and is an important ur-ban malaria transmission area.

in southern Bolivia, on the border with Ar-gentina and Paraguay, malaria is concentrated in a few pockets in the Department of tarija, where Plasmodium vivax-borne malaria predomina-tes. 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 trans-mission, Anopheles pseudopunctipenis is the res-ponsible vector species. Morbidity and mortality trends Figures 4 – 9

Malaria transmission in Bolivia has dropped considerably over the past 10 years. P. vivax-borne 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 sin-ce 2003.

R e P O R t O n t H e S i t uAt i O n O f M A l A R iA i n t H e A M e R i c A S , 2 0 0 87 0

R e P O R t O n t H e S i t uAt i O n O f M A l A R iA i n t H e A M e R i c A S , 2 0 0 8 B O l i V iA 7 1

Geographical distributionFigures 1, 12 – 19

The Municipality of Riberalta, in the De-partment 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 re-gion, 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 trans-mission, high impact operations can be expected to be successful in the short term. in 2006, the malaria program, which had pre-viously used the total populations of malaria-endemic municipalities, adjusted the population at risk. even so, Annual Parasite incidence (APi) dropped, particularly in the high-risk municipa-lities. furthermore, the number of malaria-en-demic 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, na-mely the municipality of Guayaramerin, in the Department of Pando, accounted for 11% of the total cases.

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 harves-ters in the Departments of Beni and Pando, whe-re 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 wo-men with malaria could mean that a sizeable number of such women with malaria are not be-ing 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 repor-ted in areas with higher levels of malaria trans-mission in other countries of the region, like Brazil and colombia.

in 2008, 48% of the malaria cases were diag-nosed within the first 72 hours after the onset of symptoms. late initiation of treatment in a lar-ge number of cases is apparently a determining factor in continued malaria transmission in the most endemic areas.

R e P O R t O n t H e S i t uAt i O n O f M A l A R iA i n t H e A M e R i c A S , 2 0 0 8B O l i V iA7 2

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 informa-tion exists about cases of fever among people who have no contact with the health system, their existence can be assumed in several mala-ria endemic areas, particularly in the Amazon region.

Bolivia was the second country in the re-gion to introduce the use of Acts for mala-ria treatment. The country has been using the ASu+MQ combination since 2001 as a first-line therapy for uncomplicated P. falciparum mala-ria. 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 con-trol strategies in Bolivia, its use declined simul-taneously with the drop in the number of ma-laria 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 protec-ted 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 pro-ject financed by the Global fund. in 2007, with support from the uSAiD-funded AMi initiati-ve, the llin implementation strategy was laun-ched 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 con-vocation of the GfAtM was approved in 2008.

R e P O R t O n t H e S i t uAt i O n O f M A l A R iA i n t H e A M e R i c A S , 2 0 0 8 B O l i V iA 7 3

Bolivia

Brazil

ChileParaguay

Peru

Argentina 3

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

P. vivax

1 - 73

74 - 216

217 - 315

316 - 1170

1171 - 4890

No cases

Legend

P. falciparum

1 Dot = 10 cases

9%

91%

Plasmodium species

P. vivax

Figure 2. Proportion of cases by species, 2008

P. falciparum and mixed

R e P O R t O n t H e S i t uAt i O n O f M A l A R iA i n t H e A M e R i c A S , 2 0 0 8B O l i V iA7 4

ADM1 Total casesP. vivaxP. falciparum + mixed

Figure 3. Number of malaria cases by species by ADM1 level in 2008

ADM1

2,0000 0% 50% 100%Total number of cases Percentage of total cases

4,000 6,000

Beni

Tarija

Santa Cruz

Pando

Cochabamba

La paz

Potosi

Chuquisaca 132

156

247

250

800

913

1,424

5,826

132

156

234

247

730

889

1,424

5,100

0

0

13

3

70

24

0

726 Beni

Tarija

Santa Cruz

Pando

Cochabamba

La paz

Potosi

Chuquisaca

Plasmodium species

P. falciparum and mixed P. vivax

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

Plasmodium species

P. falciparum and mixed P. vivax

2000 2001 2002 2003 2004 2005 2006 2007 2008

Year

0

10,000

20,000

30,000 28,932

14,957

13,549

17,319

14,215

19,062

17,210

12,988

8,912

2,446808 727 793 695 1,080 1,785 1,610 836

Figure 5. Number of malaria cases, 2000 - 2008

2000 2001 2002 2003 2004 2005 2006 2007 2008

Year

0

20,000

10,000

Num

ber o

f cas

es

31,4

69

15,7

65

14,2

76

20,3

43

14,9

10 18,9

95

14,6

10

9,74

8

20,1

42

30,000

40,000

00000

2

444

Num

ber o

f dea

ths

Figure 6. Number of malaria deaths, 2000-2008

2000 2001 2002 2003 2004 2005 2006 2007 2008

Year

0

4

3

2

1

00NANA 0

82

44

6

285

Num

ber o

f cas

es

2000 2001 2002 2003 2004 2005 2006 2007 2008

Year

0

300

200

100

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

NA - No Data Available

R e P O R t O n t H e S i t uAt i O n O f M A l A R iA i n t H e A M e R i c A S , 2 0 0 8 B O l i V iA 7 5

Year

2000 2001 2002 2003 2004 2005 2006 2007 2008

-5,000

-10,000

0

500

Plasmodium species

P. falciparum and mixed P. vivax

-4,076-4,222

-1,852

4,847

-3,104

3,770

-1,408

-13,975

-774-175

705385

-98

66-81

-1,638

Diff

eren

ce in

num

ber

of c

ases

Figure 8. Annual variations in number of cases

Year

2000 2001 2002 2003 2004 2005 2006 2007 2008

-20%

-40%

Per

cent

age

diff

eren

ce

Figure 9. Percentage differencein number of cases compared to 2000

-60%

-80%

0%

-69%

-55%

-41%

-34%

-51%-40%

-53%

0%

-66%

-34%

-27%

-56%

-72%-68%-70%

-67%

-48%

Plasmodium species

P. falciparum and mixed P. vivax

Num

ber

of c

ases

Year

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

10,000

20,000

30,000

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

Reported cases RBM / MDG Targets

Figure 11. Percentage of hospitalized cases, 2008

0%

100%

Percentage of cases

Oupatients

Hospitalized

R e P O R t O n t H e S i t uAt i O n O f M A l A R iA i n t H e A M e R i c A S , 2 0 0 8B O l i V iA7 6

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

Number of cases Cummulative proportion (%) of total cases

* See Annex A for a complete list.

0 1,000 2,000 3,000 4,000 0% 20% 40% 60% 80% 100%

Riberalta

Guayaramerin

Yacuiba

San Ignacio de Velasco

Bermejo

El Torno

Villa Tunari

Buena Vista

San Lorenzo (Exaltación)

Bolivar (Sena)

Baures

Carapari

Nueva Esperanza (Nuevo M.)

Toro Toro

Villamontes

Victoria (Puerto Rico)

Ayata 53

70

79

85

102

106

116

139

156

186

215

306

312

327

858

1,994

3,620

93%

92%

91%

90%

90%

88%

87%

86%

85%

83%

81%

79%

75%

72%

69%

60%

38%

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

Number of districts

Number of cases>1,001

501-1,000

251-500

101-250

51-100

11-50

6-10

1-5

Grand Total

0 10 20 30 40 50 60 70

19

7

23

4

7

3

1

2

��

Figure 14. Districts (ADM2) by number ofP. falciparum cases, 2008

Number of districts

101-250

251-500

11-50

6-10

1-5

Grand Total

0 2 4 6 8 10 12 14

7

3

1

1

1

13

Number ofP. falciparum

cases

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

Per

cent

age

of P

. fal

cip

arum

cas

es

Number of cases (logarithmic scale)

API0.05

20406080

105.15

2 5 10 20 50 100 200 500 1,000 2,000 5,000

0

5

10

15

20

25

Zudanez Yacuiba

Villa Nueva (Loma Alta)

Santos Mercado (Eureka)

Santa Rosa del Abuna (Nacebe)

Riberalta

Ixiamas

Guayaramerin

Bolivar (Sena)

Bella Flor (Costa Rica)

BauresAyataAcasio

250

25

R e P O R t O n t H e S i t uAt i O n O f M A l A R iA i n t H e A M e R i c A S , 2 0 0 8 B O l i V iA 7 7

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

Legend

0.01 - 1.00

1.01 - 5.00

Municipal API

5.01 - 10.00

10.01 - 50.00

50.01 - 100.00

100.01 - 500.00

Bolivia

Brazil

ChileParaguay

Peru

Argentina

Figure 17. Population by malariatransmission risk, 2008

High risk (API > 10/1000)

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

Low risk (API < 1/1000 )

Malaria free areas (No indigenous transmission)

7%5%2%

86%

Population

R e P O R t O n t H e S i t uAt i O n O f M A l A R iA i n t H e A M e R i c A S , 2 0 0 8B O l i V iA7 8

Nueva Esperanza (Nuevo)

Bolivar (Sena)

Guayaramerin

Ayata

Riberalta

San Lorenzo (Exaltacion)

Santos Mercado (Eureka)

Villa Nueva (Loma Alta)

Ravelo (Moro Moro)

Gral. Juan Jose Perez

Baures

Victoria (Puerto Rico)

Toro Toro

Ingavi (Humaita)

Buena Vista

Villa Serrano

Carapari

Bella Flor (Costa Rica)

Acasio

Santa Rosa del Abuna

Bermejo

San Ignacio de Velasco

Yacuiba

Azurduy

El Torno

Teoponte

Agua Dulce (Pto. G. More)

Zudanez

Ixiamas

Porvenir (Campo Ana)

Villa Tunari

Padcaya

Padilla 21

24

215

23

45

4

29

26

306

37

858

327

312

23

7

23

106

16

186

12

85

70

116

23

36

35

28

156

3,620

53

1,994

139

102

3.35

3.69

4.38

5.36

5.81

6.02

6.15

6.19

6.36

6.69

6.82

6.99

8.03

8.97

9.03

10

10.61

10.7

12.82

13.19

14.04

15.35

22.02

27.06

28.57

29.89

36.32

38.83

41.01

42.67

44.33

55.87

105.15

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

0 2,000 4,000Number of cases

0 50 100 150API

* See Annex A for a complete list

API (cases/ 1000 people at risk)

0 105.15

2000

2001

2002

2003

2004

2005

2006

2007

2008 8,644,057

8,268,107

8,198,269

5,749,219

5,856,511

5,712,922

5,486,743

6,753,268

4,857,790

678,535

849,532

720,000

2,887,000

2,482,000

1,544,000

2,377,000

100,000

0

516,248

438,495

438,000

423,000

461,000

339,000

666,000

1,434,000

2,828,000

188,804

271,388

271,000

368,000

427,000

1,429,000

294,000

337,000

742,000

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

Year Malaria freeareas (Noindigenoustransmission)

Low risk(API < 1/1000)

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

High risk(API >10/1000)

Year Number of slidesexamined

Number of slidespositive

Slide PositivityRate (%)

2000

2001

2002

2003

2004

2005

2006

2007

2008 6.1

8.05

9.11

9.97

9.13

12.85

10.38

12.82

21.85

9,748

14,610

18,995

20,142

14,910

20,343

14,276

15,765

31,469

159,826

180,316

208,616

202,021

163,307

158,299

137,509

122,933

143,990

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

100,000 200,000 100,000 200,000

Year

Diagnostic Method

Microscopy RDTs

0

Number of cases

0

Number of cases

200020012002200320042005200620072008 159,826 5,000

180,316208,616202,021

6,0006,000

163,307158,299

137,509122,933

143,990

Figure 21. Cases diagnosed by microscopyand RDTs, 2000-08

R e P O R t O n t H e S i t uAt i O n O f M A l A R iA i n t H e A M e R i c A S , 2 0 0 8 B O l i V iA 7 9

Figure 22. Number of cases diagnosedand cases treated, 2000-2008

Year2000

2001

2002

2003

2004

2005

2006

2007

2008

Diagnosed casesCases treatedDiagnosed casesCases treated

Diagnosed casesCases treated

Diagnosed cases

Cases treatedDiagnosed cases

Cases treated

Diagnosed casesCases treated

Diagnosed casesCases treated

Diagnosed cases

Cases treatedDiagnosed cases

Cases treatedDiagnosed cases

Cases treated

0 10,000 20,000 30,000

Number of cases diagnosed/treated

ADM1 Examined Total cases SPR (%)

Beni

Tarija

Santa Cruz 3.52

3.91

8.87

913

1,424

5,826

Pando

Cochabamba

La paz 5.99

14.46

4.35

247

250

800

Potosi

Chuquisaca

Oruro 0

2.36

7.81

0

132

156

25,914

36,375

65,694

4,121

1,729

18,393

---

5,602

1,998

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

--- Data not available

52%

48%

Time span between onset of symptoms and diagnosis

>72 hours

<72 hours

Figure 24. Time span between onset of symptomsand diagnosis, 2008

Figure 25. Number and percentageof cases by age group, 2008

Number of cases

<55-1415-49>50 9.3%

54.9%26.4%

9.4%

2,0000 4,000

Figure 26. Number and percentageof cases by locality type, 2008

Number of cases

UrbanRural

0 2,000 4,000 6,000 8,000

89.0%11.0%

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

Number of cases

PregnantNot pregnant

0 500 1000 1500

93.7%6.3%

Figure 28. Number and percentage of casesin indigenous population, 2008

No Data Available

2000 2001 2002 2003 2004 2005 2006 2007 2008

Year

7.8 5.1 5.1 3.9 4.7 5.49.4 11.1 8.6P

erce

ntag

e of

P. f

alci

par

um c

ases

100

0

20

40

60

80

Figure 29. Proportion of P. falciparum cases, 2000-2008

R e P O R t O n t H e S i t uAt i O n O f M A l A R iA i n t H e A M e R i c A S , 2 0 0 8B O l i V iA8 0

Figure 34. Sources for malaria control funds by year, 2000-08

2000 2001 2002 2003 2004 2005 2006 2007 2008

Year

US

$

0

1M

2M

Financing sources

USAID

UN agencies

Other bilateral funds

Global Fund

Government

NA - Data not available

Figure 30. Number of ACT treatmentsdistributed by year, 2000-08

2000 2001 2002 2003 2004 2005 2006 2007 2008

Num

ber

of A

CT

trea

tmen

ts

0

1,000

2,000

782

1,6221,785

1,080

700793727808

Year

Figure 31. Indoor residual sprayingcoverage by year, 2000-08

2000 2001 2002 2003 2004 2005 2006 2007 2008

Num

ber

of p

eop

le p

rote

cted

0

712,

540

512,

288

97,0

28

8,60

0

8,60

0 69,4

00

26,2

96

19,1

30

8,97

5200,000

400,000

600,000

800,000

Year

Figure 33. Number of ITNs distributed by year, 2000-08

2000 2001 2002 2003 2004 2005 2006

6,000 6,000

2007 2008

Year

Num

ber

of b

edne

ts

0

4,000

2,000

6,000

Figure 32. Number of LLINs distributed by year, 2000 - 2008

2000 2001 2002 2003 2004 2005 2006

16,400

40,000

2007 2008

Year

Num

ber

of b

edne

ts

0

14,000

5,000

30,000

20,000

10,000

40,000