Plan estratégico de prevención de la reintroducción de la malaria en el paraguay

Objectives

The 2015–2019 plan seeks to prevent the reintroduction and re-establishment of malaria transmission in Paraguay, sustain zero locally acquired cases, preserve elimination gains and support certification of malaria elimination. It responds to continuing risks from imported infections, population mobility, porous borders, receptive environments and the presence of competent Anopheles vectors.[1][2][3][4]

• Maintain zero indigenous malaria cases, while ensuring prompt detection and treatment of imported cases.[4]
• Strengthen epidemiological surveillance, timely quality-assured diagnosis, comprehensive treatment and patient follow-up through integrated health services.[5][6][3]
• Integrate community malaria surveillance with the National Health Surveillance System and malaria diagnosis with the National Laboratory Network.[3]
• Reduce vulnerability through surveillance at entry points and secondary contact sites, case detection among travellers and migrants, risk communication, and cross-border information exchange.[7][8][9]
• Reduce receptivity through entomological characterisation, vector surveillance, insecticide-resistance monitoring, focal vector control and preparedness for outbreaks or case clusters.[3][10][4]
• Strengthen information, education and communication for travellers, mobile populations, border communities, health workers and communities in vulnerable or receptive areas.[6][11]
• Formalise monitoring and evaluation, including surveillance of indigenous cases and the timely detection and treatment of imported cases.[3][4]

The framework is aligned with the Ministry of Public Health and Social Welfare’s institutional strategic plan, particularly its stewardship and institutional-development, health-equity, and transparent, efficient and quality-management axes. It also reflects World Health Organization and Pan American Health Organization approaches to malaria surveillance and elimination.[12][13]

Implementation

Implementation combines decentralised delivery through the health-service network with national technical leadership by the National Malaria Eradication Service, known as SENEPA, and surveillance oversight by the Directorate-General for Health Surveillance. Activities are progressively integrated into public and private health services, laboratories, primary care and hospitals, while retaining specialised national capacity for laboratory quality assurance, entomology, vector control, medicines management and case investigation.[14][7][15][16]

• Organise case detection through passive presentation at health facilities, proactive screening of people with relevant travel or clinical history, and reactive searches around identified cases and foci.[17][18]
• Ensure immediate notification of confirmed cases to epidemiological and laboratory structures, followed by investigation, focus classification, risk assessment, treatment, follow-up and closure of investigations.[19][20]
• Provide diagnosis through microscopy, rapid diagnostic tests in defined settings and molecular methods for sensitive investigations or research; confirm parasite species, stage and density within 24 hours of specimen collection.[9][16]
• Strengthen the National Laboratory Network by incorporating Malaria Diagnostic Units and trained private laboratories, with the Central Public Health Laboratory as the national malaria reference laboratory and manager of diagnostic quality control.[21][22]
• Apply internal slide review, indirect cross-checking, direct external assessment and annual external performance evaluation to assure diagnostic quality.[21][23]
• Deliver clinical care through defined referral levels: primary services identify suspects and collect specimens; health centres coordinate referrals and manage mild adverse effects; regional and district hospitals manage complicated cases; and specialised hospitals receive exceptional severe cases.[15]
• Initiate treatment within 24 hours of diagnosis, supervise adherence and monitor cure, including scheduled post-treatment verification for microscopically confirmed Plasmodium vivax and Plasmodium falciparum cases.[13][24]
• Maintain medicine availability through requirements planning by the National Malaria Elimination Programme technical team, procurement by central operational authorities, regional distribution and minimum stock management.[22][13]
• Conduct investigations around confirmed cases within a 500-metre radius, assess vectors and breeding sites, and apply three cycles of indoor residual spraying at three-month intervals where indicated.[10]
• Maintain sentinel entomological surveillance across ecological zones, with quarterly collection of adult and immature Anopheles mosquitoes, annual resistance monitoring and additional case-triggered investigations.[25][26]
• Engage community volunteers, who identify suspected cases and collect thick blood-film samples, alongside SENEPA evaluators who collect weekly epidemiological information and direct samples to diagnostic services.[14]
• Coordinate entry-point and traveller surveillance with migration, airport, tourism, airline, travel-agency, university and foreign-affairs partners; information on arrivals from endemic African countries is transmitted within 24 hours for follow-up.[8][27]
• Collaborate with the Pan American Health Organization, World Health Organization, education, labour, migration, social-security, military, police, private-sector, university and civil-society partners in an intersectoral response.[12]

Governance operates through SENEPA’s national headquarters, 18 geographical zones and 40 sectors, coordinated with Regional Epidemiological Units and the integrated health-services network. Sector-level personnel hold operational responsibilities, while national and regional institutions coordinate laboratory support, surveillance, procurement, clinical management and vector-control actions.[28][24][29]

Monitoring uses routine reports at administrative health levels, including quarterly, semi-annual and annual reporting. Key indicators include zero indigenous cases, 100% timely detection and treatment of imported cases, case and focus investigation, diagnostic quality assurance, treatment availability, rapid-test performance, vector identification and insecticide resistance.[4][30][18]

Financing is primarily through SENEPA institutional resources transferred by the Ministry of Public Health and Social Welfare. The approved 2015 SENEPA budget was 92,102,651,252 Paraguayan guaraníes, with approximately 22% estimated for the National Malaria Programme, equivalent to 19,785,578,890 Paraguayan guaraníes; this programme allocation was an estimate because the budget was not disaggregated by programme.[31]

Monitoring & Evaluation

The plan establishes a comprehensive surveillance, monitoring and quality-assurance framework to prevent malaria reintroduction, centred on rapid detection and management of imported cases, investigation of cases and transmission foci, integrated vector surveillance, and formal reporting across health-service and laboratory networks.[13][17][4]

• Monitor the principal impact and outcome indicators against a 2012 baseline: maintain zero indigenous malaria cases and achieve 100 percent timely detection and timely treatment of imported cases annually during 2015–2019.[4]
• Produce quarterly, semi-annual and annual implementation reports at each administrative health level, covering public and private establishments in malaria-risk areas.[30]
• Track service readiness and response, including the proportion of establishments in vulnerable or receptive areas, timely treatment availability, treatment compliant with national standards, investigated cases, and investigated and classified foci.[30]
• Record cases by parasite species, sex, age, detection type and locality, including imported, autochthonous, introduced, induced and relapsed cases, as well as malaria hospitalisations and deaths.[30][18]
• Measure treatment timeliness by intervals from symptom onset, including within 24 hours, 24–48 hours, 48–72 hours and more than 72 hours.[18]
• Maintain active, passive, proactive and reactive case detection, with reactive searches following an index case or outbreak and scheduled proactive searches in historical foci and other identified risk areas.[30][18]
• Require immediate notification of positive malaria results to regional laboratories, local epidemiologists and treating staff, including notification and referral arrangements for positive results from private laboratories.[19]
• Use standard case and specimen records, including EP2 forms, acute febrile syndrome forms where applicable, consolidated malaria-results spreadsheets and case-investigation forms, with copies retained and forwarded through regional epidemiological structures.[19][20]
• Conduct case and focus investigations, assess receptivity and vulnerability, classify foci, plan control actions, complete investigation reports and close investigations.[17][29]
• Follow microscopically confirmed cases using Verification of Cure Slides to assess treatment adherence and effectiveness. For Plasmodium vivax, follow-up is scheduled through day 63 after treatment begins; for Plasmodium falciparum, it continues through day 28.[13]
• Integrate surveillance at points of entry and secondary contact points, with airport information on travellers arriving from endemic African areas transmitted within 24 hours to the National Focal Point and National Malaria Control Programme.[8][27]
• Undertake active case-finding annually in localities with land-border crossings and twice yearly among identified migrant student populations.[32]
• Apply laboratory quality assurance through internal review of every thick-blood-film request, indirect external cross-checking, monthly consolidation of laboratory results and immediate referral of positive slides.[21][23]
• Conduct direct external laboratory assessment at least annually through known-result slide panels and continuing-education questionnaires, covering parasite detection, species and stage identification, and parasite-density estimation.[23]
• Participate in the annual External Performance Evaluation Programme for Microscopic Malaria Diagnosis coordinated by the Pan American Health Organization, and establish the Central Public Health Laboratory as the malaria diagnostic reference laboratory through transfer of slide-panel coding in 2016.[23][22]
• Monitor rapid diagnostic test use and performance, including agreement with microscopy, testing at sites using rapid tests, and positivity by species.[30]
• Conduct entomological surveillance by ecological zone, including quarterly sampling during the first two years, annual resistance and susceptibility monitoring, and additional investigations whenever cases are notified.[25][10][26]
• Assess adult-vector density and behaviour, breeding sites, larval presence, insecticide susceptibility, residual insecticide activity and intervention effectiveness to guide vector-control decisions.[7][3][10]

Costing & Financing

Financing is principally routed through the National Malaria Eradication Service, known as SENEPA, using institutional resources transferred directly by the Ministry of Public Health and Social Welfare. The available material identifies budget estimates and medicine-procurement mechanisms, but does not provide a fully costed 2015–2019 implementation plan, activity-level expenditure, quantified funding gap or economic assumptions.[31][33][13]

• Allocate 1.0 percent of the employer contribution to the Social Security Institute to SENEPA programmes and 0.5 percent to epidemiological programmes of the Ministry of Public Health and Social Welfare under Laws 1429/99 and 2311/03.[31]
• Operate SENEPA through Funding Source 30, Institutional Resources, using a monthly cash plan based on the approved annual budget and financial plan; SENEPA does not recover costs.[31]
• Provide an approved SENEPA budget of 92,102,651,252 Paraguayan guaraníes in 2015, of which approximately 22 percent, or an estimated 19,785,578,890 Paraguayan guaraníes, was allocated to the National Malaria Programme because the overall budget was not disaggregated by programme.[31]
• Estimate National Malaria Programme allocations at 18,113,306,834 Paraguayan guaraníes in 2013 and 21,949,281,395 Paraguayan guaraníes in 2014, using the same allocation assumptions.[33]
• Estimate programme resources from the 2016–2017 draft multi-year SENEPA budget at 24,511,867,948 Paraguayan guaraníes for 2016 and 25,195,005,156 Paraguayan guaraníes for 2017.[33]
• Plan antimalarial medicine requirements through the National Malaria Elimination Programme technical team, using safety margins for potential imported or locally acquired cases, before processing procurement through health-information and procurement authorities.[22]
• Acquire medicines through tenders, procurement procedures associated with specific donations, and donations from the Pan American Health Organization; SENEPA distributes donated medicines from regional stocks in Panama to regional health stores.[13]
• Maintain minimum medicine stocks and supply requesting facilities within no more than 24 hours when required, supported by resources for freight, airport reception, central storage and regional distribution.[13]
• Maintain operational resources for diagnostic supplies, medicines and reagents, laboratory expansion and quality assurance, training, entomology staffing, surveillance, logistics and vector-control operations, although no monetary values are assigned to these inputs.[9][16][4]
• Optimise resources by coordinating integrated vector-management interventions and geographically targeting entomological investigations where they can improve cost-effectiveness.[34][25]