1. MALARIA IN PARAGUAY Current scenario and forecasting system Antonieta Rojas de Arias arias1@telesurf.com.py Antonieta Rojas de Arias arias1@telesurf.com.py

2. 2005 Organización Panamericana de la Salud 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

3. 2005 Organización Panamericana de la Salud 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"

4. 2005 Organización Panamericana de la Salud MALARIA 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

5. 2005 Organización Panamericana de la Salud Distribution of population* according to risk area, in the Americas

6. 2005 Organización Panamericana de la Salud 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

7. 2005 Organización Panamericana de la Salud DEATHS ATTRIBUTED TO MALARIA (1998-2004) 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

8. 2005 Organización Panamericana de la Salud PARAGUAY: Population at Risk of Malaria Transmission, 1998-2004 (in thousands)

9. 2005 Organización Panamericana de la Salud PARAGUAY: Population at Ecological Risk of Malaria Transmission According to Level of Transmission Risk, 1998-2004 (in thousands)

10. 2005 Organización Panamericana de la Salud PARAGUAY: Malaria Morbidity, 1998-2004 (number of positive blood slides)

11. 2005 Organización Panamericana de la Salud PARAGUAY: Malaria Morbidity According to Level of Transmission Risk, 1998-2004 (number of positive blood slides)

12. 2005 Organización Panamericana de la Salud PARAGUAY: Malaria Morbidity According to Parasite Species (In All Risk Areas), 1998-2004

13. 2005 Organización Panamericana de la Salud PARAGUAY: Passive vs. Active Case Detection, 1998-2004 (% of Blood Slides Examined)

14. 2005 Organización Panamericana de la Salud PARAGUAY: Annual Blood Examination Rate (ABER) in Malarious Areas, 1998-2004

15. 2005 Organización Panamericana de la Salud PARAGUAY: Slide Positivity Rate (SPR), 1998-2004

16. 2005 Organización Panamericana de la Salud PARAGUAY: Antimalarial Drugs Used, 1998- 2004

17. 2005 Organización Panamericana de la Salud PARAGUAY: National Budget and Non- Budgetary Contributions to Malaria Control Programs, 1998-2004 (in US$)

18. 2005 Organización Panamericana de la Salud PARAGUAY: Annual $US Funds / Person in Malarious Areas, 1998-2004

19. THE VICTIMS

21. Malaria in 2005

22. Corridor of Transmission CANINDEYÚ CAAGUAZÚ ALTO PARANÁ

23. CLIMATIC CONDITION BEHAVIOUR IN 2010

24. 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)

25. Anopheles spp. (A. darlingi and others) THE VECTOR

26. INTRADOMICILEEXTRADOMICILE An.darlingiXX An.albitarsisXX An. strodeiXX An.trianulatusXX An.noroestenciXX An.brasiliensisXX An.rondoniXX An.argyrytarsisXX An. osvaldoiXX An.galvaoiXX An.laneiX An.parvusXX An.lutziXX An. antunesisXX An.punctimaculaX An.mediopuntatusXX An. fluminensisXX An. neomaculipalpusX An. apicimáculaX An.minorXX An.pseudopuntipennisX An. peryassuiX ANOPHELINE SPECIES BREEDING SITES IN PARAGUAY Fuente: Secc.Entomología - SENEPA

27. MALARIA CASES AND ANOPHELINE DENSITIES Fuente: Secc.Estadística-SENEPA

28. 2005 Organización Panamericana de la Salud THE ENVIRONMENT

29. HISTORICAL SERIES OF CASES 1966-2000

30. 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 BASELINE

31. METHODOLOGY 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 models Validation 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 models Validation of the models empirical-statistical Analyses of sensitivity of the models

32. 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

33. STRATIFICATION 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

34. 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.

35. MONTHLY FORECASTING OF THE MALARIA CASES IN ALTO PARANÁ

36. 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. CONCLUSIONS

37. 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.

38. Acknowledgements 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!!!