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Nicaragua has experienced a 97 percent decrease in reported cases in the last decade and is implementing a spatially progressive strategy to achieve national elimination.

Overview Nicaragua has experienced a 97 percent decrease in re-ported malaria cases between 2000 and 2010, from 23,878 cases to only 692 cases.1 Malaria transmission in Nicaragua is primarily Plasmodium vivax; in 2010, 78 percent of cases were P. vivax and the remaining 22 percent were P. falciparum.1 Increased transmission is found along the Atlantic coastal region in the municipalities of Chinandega, Chontales, Jinotega, Matagalpa, Nueva Segovia, and Río San Juan.2 The primary mosquito vector responsible for malaria transmission is Anopheles albimanus; secondary vectors include An. pseu-dopunctipennis and An. aquasalis.3 The highest period of transmission occurs during the September-to-January rainy season. Vector control is a challenge in Nicaragua due to the variety of breeding conditions tolerated by An. albimanus, high densities of adult vectors during the rainy season, and historically rapid development of resistance to insecticides.4

In 2008, 66 percent of Nicaragua’s malaria cases were report-ed in urban areas.5 Malaria rates are typically higher among children under five years old, and males are more affected by malaria than females.2 In 2008, 26 percent of the total cases occurred among indigenous people.5 Of the 154 municipali-ties in Nicaragua, 55 percent are categorized as low risk and 45 percent as near-zero risk with sporadic local malaria cases.5 In 2010, of the total population in Nicaragua, only three percent is at high risk.1 Current malaria control efforts include prompt diagnosis and treatment, indoor residual spraying, bed net distribution, and mosquito breeding-site control.5

Progress Toward EliminationDuring the 1930s, up to 60 percent of the Nicaraguan population had malaria. From 1934 to 1948, 22 percent of all registered deaths were due to malaria.4 In response to the high burden, a national malaria control program was started in 1947 and indoor residual spraying (IRS) was used as the primary control intervention.4, 8 Deaths from malaria progres-sively declined, however, overall incidence remained high.8

692

0

84

0.12

0.12

Reported cases of malaria(78% P. vivax)

Deaths from malaria

% of population at risk(total population: 5.7 million)

Annual parasite incidence (cases/1,000 total population/year)

% Slide positivity rate

At a Glance1

In accordance with the World Health Organization’s Global Malaria Eradication Program, Nicaragua set a goal in 1959 to eliminate malaria.9 IRS reduced malaria cases by more than 50 percent over the next few years. However, with the de-velopment of resistance to insecticides, the program scaled back its spraying efforts and cases resurged, causing the pro-gram to introduce alternative and less-effective insecticides.9

Mass drug administration (MDA) was first attempted in 1967. However, when the effects of MDA were not realized, popular cooperation declined and in 1969 vector control was again the favored intervention.9 By 1979, vector control activities had nearly ceased due to a civil war being waged in Nicaragua, which caused incidence to rise to seven cases per 1,000 population.4 In 1981, MDA was reintroduced and inci-dence reduced slightly; however, by March 1982 the number of malaria cases returned to 1979 levels.8 From 1983 to 1989, malaria control activities were disbanded again due to the civil war in Nicaragua, and by 1989 cases had increased to 12 per 1,000 population.4

Source: World Health Organization, World Malaria Report 2011

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Nicaragua experienced its worst recorded malaria epidemic in 1996, with more than 75,000 cases.10 The number of P. falciparum cases increased from 1,524 cases in 1994 to 4,103 cases in 1995.1, 6 Nicaragua had adopted a new global malaria control strategy in 1992. However, its goals to improve disease control through case management, vector control, and early detection of epidemics were not formally adopted until 1999.11 Once the activities were implemented, positive results were seen; case numbers decreased from 33,903 in 1999 to 7,695 in 2002.1 In 2003, as malaria case totals continued to decrease, Nicaragua received a Global Fund Round 2 grant with the objectives of reducing transmis-sion in 36 high-risk municipalities, particularly malaria caused by P. falciparum, and maintaining the reduction in mortality recorded in recent years.12

In 2006, Nicaragua partnered with the Pan American Health Organization to outline objectives for a regional strategic plan for malaria to be implemented through 2010. The objec-tives of the plan included malaria prevention, surveillance, cost-effective vector management, early diagnosis and treat-ment, and a strengthened health system. The activities in the regional strategic plan complement Nicaragua’s national strategic plan for malaria.

With continued support from the Global Fund, Nicaragua strengthened capacity for diagnosis and treatment at the local level and implemented vector control activities using DDT.13 The focus of Nicaragua’s Global Fund Round 7 grant in 2007 was on control in 117 municipalities, which repre-sented 76 percent of the total municipalities and covered

Malaria Transmission Limits

0 100 200 300 400 Kilometres 0 100 200 300 400 Kilometres

Plasmodium falciparum Plasmodium vivax

P. falciparum/P. vivax malaria risk is classified into no risk, unstable risk of <0.1 case per 1,000 population (API) and stable risk of ≥0.1 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.

Water

P. falciparum free

Unstable transmission (API <0.1)

Stable transmission (≥0.1 API)

Water

P. vivax free

Unstable transmission (API <0.1)

Stable transmission (≥0.1 API)

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the entire Pacific coastal region.14 A subsequent Global Fund Round 9 grant is supporting Nicaragua’s implementation of a phased approach to elimination. It focuses on pre-elimina-tion in 37 municipalities (24 percent of the total municipali-ties), and covers the central and Atlantic coastal regions of the country.7

As a result of intense malaria control activity, Nicaragua achieved a 50 percent reduction in the number of cases from 2007 to 2009, and at least 50 percent of the population at high risk are sufficiently covered by malaria prevention inter-ventions.1 With continued progress under the Global Fund Round 9 grant, Nicaragua will be able to advance toward its malaria goals and make important strides to reaching national elimination.

Reported Malaria Cases

Nicaragua reached a record of more than 75,000 cases in 1996 due to poverty, social collapse, and government decentralization.4, 6 Since the mid-1990s, Nicaragua has been successful in achieving a substantial decline in its malaria burden.

Source: World Health Organization, World Malaria Report 2011

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Num

ber

of

case

s

Eliminating malaria in the NICARAGUA

GNI per capita (US$) $1,110

Country income classification Lower middle

Total health expenditure per capita (US$) $103

Total expenditure on health as % of GDP 9

Private health expenditure as % total health expenditure

47

Eligibility for External Funding15–17

Economic Indicators18

The Global Fund to Fight AIDS, Tuberculosis and Malaria

Yes

U.S. Government’s President’s Malaria Initiative No

World Bank International Development Association Yes

GOAL: By 2014, strengthen current efforts to eliminate malaria in four municipalities, move to the pre-elimination phase in seven municipalities, and continue malaria control efforts in 26 municipalities.7

610 cases

762 cases

692 cases

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Challenges to Eliminating MalariaRural-to-urban migrationMalaria transmission in Nicaragua originates mainly in the rural areas surrounding large cities. Within these areas there has been an increase of squatter settlements, which create unsanitary conditions and additional mosquito breeding grounds.6 Though many of the reported cases are in urban settings, frequently these cases originate from residents in peri-urban settings who visit the nearest city to receive treatment.5 The rural-to-urban migration, which can perpetu-ate the spread malaria, is an additional incentive to improve diagnosis, treatment, and surveillance.

Mosquito breeding groundsWhile the mean annual rainfall in Nicaragua has declined over the last 15 years, the proportion of rainfall that occurs

in heavy episodes has increased since 1960.19 This increase in torrential rainfall results in the formation of large swamps in Managua’s coastal areas, which create ideal breeding grounds for mosquitoes and enable continued transmission.6 Since Nicaragua’s primary vector, An. albimanus, has shown resistance to insecticides, vector surveillance and breeding ground management are essential to achieve elimination.

ConclusionIn Nicaragua, 84 percent of the population is at risk of malaria, and emphasis for control and prevention is being placed on those groups living in high-risk municipalities located along the Atlantic coast.20 Nicaragua is working to interrupt trans-mission in 37 municipalities to continue its spatially progres-sive strategy to achieve national elimination.7

Eliminating malaria in the NICARAGUA

Sources1. WHO. World Malaria Report 2011. Geneva: World Health Organization; 2011.2. PAHO. Health in the Americas, 2007. Volume II-Countries: Nicaragua. 2007.3. Sinka M, Rubio-Palis Y, Manguin S, Patil A, Temperley W, Gething P, et al. The dominant Anopheles vectors of human malaria in the Ameri-

cas: occurrence data, distribution maps and bionomic precis. Parasites & Vectors 2011; 3(1): 72.4. Garfield R. Malaria control in Nicaragua: social and political influences on disease transmission and control activities. Lancet 1999;

354(9176): 414–8.5. PAHO. Report on the Situation of Malaria in the Americas. Pan American Health Organization, 2008.6. PAHO. Regional Core Health Data System-Country Profile: Nicaragua. 2001.7. Nicaragua Country Coordinating Mechanism. Round 9 Global Fund grant: stop the local transmission of malaria, focused upon pre-elimi-

nation in 37 of the country’s municipalities. Nicaragua: The Global Fund to Fight AIDS, Tuberculosis and Malaria; 2009.8. Garfield RM, Vermund SH. Changes in malaria incidence after mass drug administration in Nicaragua. Lancet 1983; 2 (8348): 500–3.9. Garfield RM, Vermund SH. Health education and community participation in mass drug administration for malaria in Nicaragua. Soc Sci

Med 1986; 22 (8): 869–77.10. Garfield R. Malaria control in Nicaragua: social and political influences on disease transmission and control activities. Lancet 1999; 354

(9176): 414–8.11. Pan American Health Organization. Epidemiological Bulletin. 2001; 22(1).12. Federacion Red NICA SALUD. Round 2 Global Fund grant: Commitment and action against malaria. Nicaragua: The Global Fund to Fight

AIDS, Tuberculosis and Malaria; 2002.13. RBM. Global Malaria Action Plan: Part III: Regional Strategies: The Americas. 2010.14. Nicaragua Country Coordinating Mechanism. Round 7 Global Fund grant: Using a humanistic and social approach from the community, to

contain HIV/AIDS and malaria and eliminate Tuberculosis in Nicaragua, 2008–2013. Nicaragua: The Global Fund to Fight AIDS, Tuberculo-sis and Malaria; 2007.

15. IDA. International Development Association Eligibility. 2012; Available from: http://web.worldbank.org/WBSITE/EXTERNAL/EXTABOU-TUS/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. United Nations Development Programme. Climate Change Country Profile: Nicaragua. 2008.20. Ministry of Health. Health Systems Profile Nicaragua. 2008.

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Eliminating malaria in the NICARAGUA

Transmission Limits Maps SourcesGuerra, CA, Gikandi, PW, Tatem, AJ, Noor, AM, Smith, DL, Hay, SI and Snow, RW. (2008). The limits and intensity of Plasmodium falciparum

transmission: implications for malaria control and elimination worldwide. Public Library of Science Medicine, 5(2): e38.

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.

Boletines epidemiologicos (2009), Direccion de Vigilancia Epidemiologica, Ministerio de Salud, Managua, Republic of Nicaragua, website: http://www.minsa.gob.ni/vigepi/html/boletin.html (Data years 2004, 2006–2007)

GloBAl HeAlTH GRoUP PRojeCT TeAMeditor: Allison Phillips | Managing editor: Chris Cotter | Researcher and Content Developer: Harmonie Adams | Graphic Designer: Kerstin Svendsen

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.

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.

About This BriefingThis country briefing was produced through a collaboration of the Global Health Group, in partnership with the National Malaria Control Program of Nicaragua. 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.