Plan de eliminación de la malaria en Costa Rica, 2015-2020

Objectives

Costa Rica’s 2015–2020 Malaria Elimination Plan sought to progress from malaria control and pre-elimination to the elimination of national malaria transmission by 2020, consistent with Pan American Health Organization and World Health Organization recommendations. Elimination was understood as interruption of local vector-borne transmission within the country, while imported infections and occasional introduced cases could still occur.[1][2][3]Costa Rica’s pre-elimination status reflected very low incidence, including an annual parasite incidence of 0.003 per 1,000 inhabitants in 2014, but continued vigilance was required because imported infections could generate renewed local transmission.[1][2][4]

• Interrupt local vectorial transmission through active case detection, prompt confirmation and treatment, supervised radical treatment, investigation of every case, and investigation and characterisation of transmission foci.[5][3]
• Strengthen epidemiological surveillance to identify residual, inactive, active and new foci; detect asymptomatic infections; register cases centrally; and maintain information on cases, interventions, parasites and vectors.[5][6][3]
• Implement laboratory-based surveillance, including quality-assured microscopy, molecular diagnosis, standardised Giemsa staining and identification of asymptomatic malaria infections.[3][7][8]
• Reinforce integrated vector management through entomological assessment, insecticide-susceptibility monitoring, mapping of risk and transmission foci, and actions addressing vector breeding environments.[3][7][8][9]
• Promote informed community participation, prevention and risk communication, including research on population knowledge, attitudes and practices and interventions based on its findings.[3][8][10]
• Ensure timely, quality medical care for all detected cases and contacts, regardless of social-security or migration status, with treatment in accordance with national regulations and follow-up to confirm cure and treatment effectiveness.[10]
• Manage environmental risks by identifying water bodies in malarious areas and eliminating or treating those associated with residual or new transmission foci.[9]

Implementation

The plan adopted a focal, risk-based delivery model rather than assuming uniform malaria transmission nationally. A transmission focus was treated as a defined geographical locality where epidemiological and ecological conditions permit transmission, including vector breeding, resting and feeding sites and exposed populations.[1]Implementation was intended to adapt existing malaria programmes to national circumstances and depend on health-service capacity, access, communications, infrastructure and transport.[5][1]National implementation was to start in 2015 through an operational plan, updated standards, dissemination and targeted activity in active, inactive and new residual foci.[3]

• Coordinate implementation through the National Technical Team, national and local health authorities, laboratory services, the National Technical Group for Vector-borne Diseases, the National Reference Centre for Parasitology, Health Area Governing Directorates and social-promotion structures.[3][7][8]
• Assign integrated responsibilities to the Ministry of Health, institutions and communities for surveillance, care, health promotion, education and malaria and vector control, while Health Area Governing Directorates prevent reintroduction after transmission interruption.[6][3]
• Deliver surveillance through notification, central registration and epidemiological investigation of every malaria case; exhaustive investigation where cases cluster; targeted active searches for asymptomatic infections; and a database linked to a geographic information system.[5][6][3]
• Strengthen laboratory services by applying microscopic confirmation and national treatment policy, establishing diagnostic quality management, training staff, conducting external performance assessment and implementing molecular diagnostic capacity.[5][3][8]
• Undertake risk mapping, characterise foci, assess entomological profiles and insecticide resistance, supervise vector-management procedures, and coordinate cross-border meetings to address importation risks.[7][8]
• Provide medicines and follow-up through the Ministry of Health, the social-security institution and the Pan American Health Organisation, including access to first-line antimalarials and availability of medicines for chloroquine-resistant Plasmodium.[10]
• Coordinate environmental management with municipalities, civil society, private companies and other organisations to treat or remove relevant water bodies.[9]
• Build workforce capacity and sustain financing as cross-cutting requirements across all six strategic areas.[3]The extract identifies a regional Elimination of Malaria in Mesoamerica and Hispaniola proposal submitted to the Global Fund to Fight AIDS, Tuberculosis and Malaria, but does not specify a quantified national budget, allocations, funding gap or costing methodology.[6][3]
• Monitor delivery through defined actions, deadlines, responsible actors and indicators, including case-investigation coverage, surveillance-system implementation, risk-map updates, laboratory quality, trained personnel, vector-management performance, civil-society participation, treatment and cure coverage, medicine availability, and water-body management.[3][7][8][10][9]
• Seek World Health Organization certification after malaria elimination has been established.[3]

Monitoring & Evaluation

The monitoring and evaluation framework combines case-based surveillance, laboratory quality assurance, vector and environmental monitoring, social-participation measures, and time-bound implementation indicators to support malaria elimination by 2020. Every malaria case is to be notified, epidemiologically investigated and registered centrally, with surveillance information linked to a database and geographic information system.[5]

• Investigate every positive case, undertake exhaustive investigation where cases are concentrated, conduct targeted searches for asymptomatic infections, and analyse and characterise transmission foci.[6][3]
• Monitor cases, interventions, parasite behaviour and vector behaviour, including the geographical distribution and classification of cases as imported, locally acquired, introduced, recurrent or transfusion-related.[5][2][4]
• Use annual case counts and annual parasite incidence as core epidemiological measures. The transition towards elimination is associated with slide or rapid-test positivity below 5% and annual incidence of no more than 5 cases per 1,000 inhabitants, subject to national circumstances and the capacity to follow each patient individually.[5]
• Track dissemination of the plan, personnel trained, regions using the surveillance information system, the proportion of cases investigated, updated risk maps, compliance with surveillance standards, and agreements reached through cross-border meetings.[7]
• Assess laboratories through use of standardised diagnostic techniques, numbers of laboratories and staff trained, personnel applying the techniques, external-performance ratings, and reports on searches for asymptomatic infections.[8]
• Measure integrated vector management through numbers of trained technicians and professionals, entomological-profile and insecticide-resistance reports, and the number of regions meeting satisfactory evaluation criteria.[8]
• Measure social participation through updated stakeholder inventories held by Health Area Governing Directorates, the number of participating civil-society groups, and a report on population attitudes and practices concerning malaria.[8]
• Monitor health promotion through a knowledge, attitudes and practices study report in the second half of 2015 and interventions informed by its findings during 2016–2020.[10]
• Track medical care through the percentage of detected cases and contacts treated, the percentage treated in accordance with regulations, the percentage cured under the current standard, and the number of hospitals holding medicines for chloroquine-resistant Plasmodium.[10]
• Monitor environmental management through an updated risk map and the percentage of water bodies treated or eliminated in malarious areas associated with residual or new transmission foci.[9]

Expected products, actions, deadlines, responsible actors and indicators were intended to structure monitoring and evaluation.[3]Activities were scheduled from the first half of 2015 to 2020, although individual actions began at different points in 2015 or continued throughout the plan period.[7][8]The first listed surveillance action was dissemination of the 2015–2020 Malaria Elimination Plan in the first half of 2015; the responsible institution and indicator were not included in the supplied extract.[3]

Available epidemiological evidence shows six malaria cases in both 2013 and 2014.[1]In 2013, annual parasitic incidence was 0.003, two cases were autochthonous, and local transmission was considered eliminated in Limón province.[4]In 2014, recorded cases included imported Plasmodium falciparum infections from Africa, imported Plasmodium vivax infections from Nicaragua, and a recurrent Plasmodium malariae infection in an area without transmission.[4]Surveillance data were associated with the Directorate of Health Surveillance and reporting through Pan American Health Organization and World Health Organization classification processes.[4]

The extracts identify several implementing bodies, including national and local health authorities, laboratory services, the National Technical Group for Vector-borne Diseases, the National Reference Centre for Parasitology, Health Area Governing Directorates and social-promotion structures.[7][8]Health Area Governing Directorates were assigned responsibility for actions to prevent reintroduction after transmission interruption.[3]However, detailed reporting schedules, independent evaluation arrangements, escalation procedures and formal accountability consequences are not specified in the supplied material.[4][3]

Costing & Financing

Financing is recognised as a cross-cutting requirement across the plan’s six strategic areas, alongside training of health personnel.[3]The supplied extracts provide no quantified budget, expenditure framework, allocation by activity, costing methodology, funding gap or economic assumption.[6][3]

• Seek financing through the regional Elimination of Malaria in Mesoamerica and Hispaniola initiative, which was submitted to the Global Fund to Fight AIDS, Tuberculosis and Malaria.[6]
• Maintain financing for surveillance, laboratory-based surveillance, integrated vector management, social communication and participation, medical care, and environmental management; specific funding sources and amounts for these areas are not specified.[3]
• Provide antimalarial medicines through the health system, including availability of medicines for chloroquine-resistant Plasmodium in the social-security health system; associated procurement costs and financing arrangements are not specified.[10]
• Coordinate water-body treatment or removal with municipalities, civil society, private companies and other organisations; the extracts do not specify contributions, budgets or resource commitments from these partners.[9]