Argentina has been officially certified by WHO as malaria-free. How did the country achieve this milestone? What were the key elements to success?

After the Global Malaria Eradication Programme ended in the 1960s, Argentina continued on its own course to eliminate malaria from within its borders. It did this through a targeted effort based in the north of Argentina, where the malaria burden was highest (provinces of Salta, Jujuy and Misiones). Malaria efforts focused mainly on controlling mosquito breeding sites, spraying houses with insecticides, conducting active surveillance, diagnosing malaria through microscopy, and conducting case investigations to understand where infections were occurring.

Additionally, beginning in the late 1990s, Argentina and Bolivia entered into several agreements to work together on cross-border health issues, including malaria. Between 2000 and 2011, Argentina worked closely with the Bolivian Government to spray more than 22 000 homes with insecticides and take more than 25 000 blood samples in border areas to test for the presence of malaria parasites. During this period, the number of cases of malaria in Argentina fell from 440 to 0.

What systems did the country put in place to make this achievement possible? Now that Argentina is officially malaria-free, will these systems remain operational?

The government of Argentina recognized that although a vertical approach was critical to the successful elimination of malaria, maintaining zero cases would require a system that was sustainable. In recent years, the country has completely integrated its malaria programme into the national health care system; the most important change was the integration of malaria surveillance into the national surveillance system for febrile illness. All cases of fever are now entered into this national system, which allows for suspected malaria cases to be rapidly identified and tested.

Additionally, in two of Argentina’s northern provinces, where the risk of re-establishment of malaria is greatest, malaria prevention and treatment services have been integrated into an excellent primary health care system that engages a large cadre of paid community health workers. Through regular household visits, health workers help the population understand when they need to seek medical attention. They follow up on suspected malaria cases to ensure they are tested and treated. In some remote areas, community health workers are equipped with radios so that they can contact provincial health authorities for assistance to transport seriously ill patients to the nearest hospital.

Finally, Argentina has an excellent capacity to respond to disease outbreaks. For many years, health providers have been using this system to respond to outbreaks of cholera and dengue. By integrating malaria into this system, they will be able to quickly interrupt transmission should any outbreak of malaria occur.

How does Argentina stand to benefit from its new malaria-free status?

Argentina now joins the ranks of 37 other countries and overseas territories that have been certified malaria-free by the World Health Organization. The population of Argentina is now liberated from of an infection that caused illness, frequent relapses, serious disease and death. The national healthcare system will be able to focus its effort and attention on other diseases that currently pose threats to the population’s health, while maintaining vigilance to prevent the reintroduction of malaria. The country will also be able to promote itself to international businesses and tourists as malaria-free and gain economic benefits from removing an impediment to further business and social development.

 Are there lessons learned from Argentina’s malaria-elimination effort that can be applied to other countries?

The extent of the cross-border collaboration and coordination between Argentina and Bolivia is almost unprecedented. Argentina benefited from the joint activities that were critical to shortening the timeline towards malaria elimination. Bolivia also benefited from this collaboration, reducing malaria along the border and many kilometers into the interior of the country.

According to WHO’s World malaria report 2018, there was a sharp spike in malaria cases in Venezuela between 2015 and 2017. What is the potential for malaria to spread from Venezuela to Argentina?

Approximately half of the territory of Venezuela was certified malaria-free in 1960, before WHO began certifying only entire countries or overseas territories. The significant increase in cases since 2015 is the result of several factors, including an expansion of gold mining and a declining economic situation. As the economy worsens, there has been increased migration from Venezuela to other countries in the region, including Argentina.

Malaria-free countries such as Argentina and Paraguay facing the challenge of imported cases of malaria should intensify actions to prevent a reintroduction of the disease; to this end, they should ensure access to health services for migrants and conduct active malaria surveillance among populations at risk of the disease.

Argentina and Paraguay have both shown that they are fully capable of rapidly detecting imported cases of malaria and responding in a timely manner. Overall, the risk of a resurgence of malaria in both countries – although real – is low.


World Leprosy Day will take place on January 28. This year's theme focuses on the target of zero cases of leprosy-related disabilities in children.



I - ABOUT LEPROSY

 

What causes leprosy?

Leprosy is a disease caused by a bacillus, Mycobacterium leprae, also known as Hansen's bacillus. It multiplies very slowly and the incubation period can be on average about five years.

What are the symptoms?

For many people the first signs of leprosy are pale patches of skin or numbness in the fingers or toes. This is because the disease mainly affects the nerves and skin. If left untreated, it can lead to nerve damage, loss of feeling (sensation) and paralysis of muscles in the hands, feet and face.

How leprosy can be transmitted?

Leprosy is transmitted via droplets, from the nose and mouth. Prolonged, close contact with someone with untreated leprosy over many months is needed to catch the disease. You cannot get leprosy from a casual contact with a person who has Hansen's disease.

Can leprosy be cured?

Leprosy is curable with multidrug therapy (dapsone, rifampicin, and clofazimine), a combination that kills the pathogen, cures the patient, and halts transmission.
This therapy is free of cost in all the countries of the Americas. If untreated, the disease can cause progressive lesions, leading to disability and blindness.

Early diagnosis and multidrug therapy are key to eliminate the disease

How can it cause disabilities?

The bacteria attack nerve endings and destroy the body's ability to feel pain and injury. Without feeling pain, people don't realize when they injure themselves their injuries are often severe and can become infected. Changes to the skin also leave the person susceptible to ulcers, which if left untreated, can cause further damage, wounds and visible disfigurements to the face and limbs. If the facial nerve is affected, this can interfere with a person's ability to blink, which can eventually cause blindness.

 

II - LEPROSY AND CHILDREN

How many children have leprosy?

In 2016, 23 countries in the Americas reported leprosy cases and 1761 children were diagnosed with this disease. Of those, 38 had visible impairments.

What is the most common age for children to show signs of infection?

The most common age for children to show signs of leprosy is between 10 and 14.

What's the most likely source of transmission for children?

Household contact is the most likely source of leprosy transmission. But this isn't limited to just family, it can include anyone in regular and close contact with an untreated person.

What do the child rates of leprosy tell us?

Transmission to children is an epidemiological indicator that the disease is still actively being transmitted through communities. The fact that children are still contracting leprosy tells us that we need to improve the number and efficiency of public health initiatives to stop the spread of this disease.

Is multidrug therapy safe for children?

Yes, it is safe. There have not been significant reports of adverse effects from treatments in children; however, dosages should be adjusted for their weight and smaller size.

 

Are there likely to be hidden cases?

Yes. Beyond the new cases that are reported annually, there are likely to be many more adults and children living with undiagnosed leprosy. Further, there are about 6 million people who have been cured of the disease, but experience residual effects such as disability and discrimination. The majority, of all new cases (81%) occur in three countries: India, Brazil and Indonesia - which are the most highly endemic countries for leprosy.

III- ACHIEVING ZERO LEPROSY

Wasn't leprosy eliminated?

The World Health Organization declared leprosy 'eliminated as a public health problem' at a global level in 2005. This was based on a definition of less than one case per 10,000 people at the national level. This did not mean total eradication of the disease, and there were still many cases in pockets all over the world. However, once the target was reached, resources at the country level were often focused on other diseases and efforts to find and treat newcases diminished. The situation is that 27356newcases were diagnosed in the Americas in 2016.

Leprosy is closely linked to poverty. The stigma still associated with leprosy remains a barrier to ending transmission, as people are often reluctant to get diagnosed or seek help. It can also have a devastating impact on people's lives, long after they have been cured.

How does PAHO/WHO help the region of the Americas in the elimination of this disease?

The Pan American Health Organization/World Health Organization is working in partnership with the Ministries of Health, National programs, the International Federation of Anti-Leprosy Associations (ILEP) and other organizations, governments and policymakers towards achieving zero leprosy. We want to stop the transmission of leprosy, prevent disabilities and promote social inclusion by ending discrimination.

 

In 1992, PAHO/WHO began to promote the Regional Plan of Action for the Elimination of Leprosy in the Americas for coverage with multidrug therapy.
Since then, a 42% treatment coverage rate has been achieved and, since 2001, coverage has been almost universal. The Organization provides medication free of charge to all people who need it, through donations from the Novartis Foundation for Sustainable Development.

In 2016, the PAHO/WHO Directing Council adopted Resolution CD55.R9, which includes implementation of the plan for the elimination of neglected infectious diseases, including leprosy. 


alice cruz rapporteur special leprosy

A Special Note for the Region of the Americas

We must keep in mind that stigma is a social determinant of health and illness. Not only stigma can lead to delay in seeking diagnosis and in adhering to treatment, but it also impairs the availability of material and socioeconomic resources (such as sanitation, housing, work, education), as well as the social relationships that support the livelihoods of persons affected by leprosy.

Lack of material resources and substantive equality, as well as of community acceptance and support, play a major role in health inequities. Harmful stereotypes and stigma usually impact the overall living conditions of affected persons, producing multiple and negative outcomes regarding their social and physical well-being.

At least 90% of the new cases of leprosy officially reported on the American continent annually are from Brazil. However, countries were successful in eliminating leprosy as a public health problem. It means that the region can become a sort of landmark laboratory for assessing which public strategies work both in high-endemic and low-endemic countries, also regarding the elimination of stigma and discrimination.

There are not many reports of discriminatory laws in force in the Americas, but there are several reports of institutionalized discrimination at the administration of the State, such as in educational, health or social security services. Structural stigmatization is still ongoing, and misconceptions about leprosy are quite common.

Multisectoral policies are key to address the social roots of leprosy and discrimination, as well as the participation of persons affected by leprosy in the monitoring of human rights violations, enforcement of rights, awareness raising activities and counseling services.


Ministry of Health and PAHO Country Offices

  Country Name Position
1 Belize Dr. Job Joseph PAHO Focal Point
2 Bolivia Dr. Alfonso Tenorio PAHO Focal Point
3 Brazil Mr. Cassio R. Leonel Peterka Coordinator of the National Malaria Prevention and Control Program (PNCM)
4 Brazil Dr. Sheila Rodovalho PAHO National Consultant
5 Colombia Dr. Jonathan Novoa PAHO National Consultant
6 Costa Rica Dr. Adriana Alfaro Najera Officer of the Directorate of Health Surveillance
7 Costa Rica Dr. Gabriela Rey PAHO Focal Point
8 Costa Rica Dr. Enrique Perez PAHO Focal Point
9 Dominican Republic Dr. Grey Idalia Benoit Epidemiological Surveillance, CECOVEZ
10 Ecuador Dr. Hector R.Veloz PAHO National Consultant
11 French Guiana Dr. Edouard Hallet Internal Public Health and Social Medicine
12 Barbados Dr. Jean Marie Rwangabwoba  PAHO Focal Point
13 Guyana Dr. Horace Cox Director of Vector Control Services of the Ministry of Health of Guyana
14 Guyana Dr. Jean Seme Alexandre PAHO Focal Point
15 Guatemala Dr. Romeo Montoya PAHO Focal Point
16 Guatemala Dr. Ricardo Rosales PAHO National Consultant
17 Haiti Dr. Frantz Lemoine Coordinator of the National Malaria Control Program (NMCP)
18 Haiti Dr. Jean Denis Gladzdin PAHO National Consultant
19 Honduras Dr. Rosa E. Mejía PAHO National Consultant
20 Mexico Dr. Hector Olguín Head of the Malaria Program of the Ministry of Health of Mexico
21 Mexico Dr. Jose Cruz Director of Epidemiological Surveillance of the Ministry of Health of Mexico
22 Mexico Mr. Federico Zumaya PAHO National Consultant
23 Mexico Dr. Maria Jesus Sanchez PAHO Focal Point
24 Nicaragua Dr. Guillermo Gonzalvez PAHO Focal Point
25 Nicaragua Dr. Marta Reyes Alvarez Director General of Surveillance for Health of the Ministry of Health of Nicaragua
26 Panama Dr. Lizbeth Cerezo Focal Point of the Strategic Plan for the Elimination of Malaria of the Ministry of Health of Panama
27 Panama Dr. Manuel Mancheno PAHO International Consultant
28 Peru Dr. Karim Pardo Official of the General Directorate of Strategic Interventions in Public Health
29 Peru Dr. Monica Guardo PAHO Focal Point
30 Suriname Dr. Helen Hiwat Coordinator of the National Malaria Program
31 Suriname Dr. Oscar Lapouble PAHO Focal Point
32 Venezuela Dr. Magda Magris PAHO National Consultant
33 Venezuela Dr. Daniel Vargas PAHO International Consultant


Non-Government Organizations and Multilateral Institutions

  Country Name Position
34 Panama Dr. Emma Iriarte Executive Secretary of Mesoamerica Health Initiative and Regional Initiative for the Elimination of Malaria in Mesoamerica and the Dominican Republic (IREM) of the Inter-American Development Bank (IDB)
35 Panama Mr. Edison Soto Consultant of IREM, IDB
36 Panama Dr. Alvaro Gonzalez Coordinator of the Mesoamerica Health Initiative (ISM) – IREM, IDB
37 Washington, DC Dr. Keith Carter Independent Consultant, IDB
38 Panama Mr. Mauricio Dinarte Technical Officer ISM-IREM, IDB
39 Atlanta, USA Dr. Kumar V. Udhayakumar    Head of the Laboratory Research and Development Unit, Malaria Section, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention (CDC)
40 Atlanta, USA Dr. Alexandre Macedo de Oliveira  Division of Parasitic Diseases and Malaria, CDC
41 Washington, DC Ms. Rebecca Minneman Malaria Advisor for Latin America and the Caribbean, the United States Agency for International Development (USAID)
42 Geneva, Switzerland Ms. Annelise Hirschmann Regional Manager of Latin America and the Caribbean, The Global Fund
43 Geneva, Switzerl Ms. Yira Tavarez Monitoring and Evaluation Officer of the Latin America and the Caribbean Region, The Global Fund
44 Geneva, Switzerland Mr. Yamil Silva Monitoring and Evaluation Officer of the Latin America and the Caribbean Region, The Global Fund
45 Panama Mr. Sebastian Salvador Regional Program Manager for Mesoamerica, CHAI
46 Geneva, Switzerland Ms. Charlotte Rasmussen Coordinator of Drug Efficacy and Response of the Global Malaria Program, World Health Organization
47 Washington, DC Dr. Luis G. Castellanos Unit Chief of Neglected, Tropical and Vector Borne Diseases, PAHO
48 Washington, DC Dr. Roberto Montoya Regional Advisor for the Malaria Program, PAHO
49 Washington, DC Dr. Maria Paz Ade Advisor of Diagnosis and Management of Malaria Supplies, PAHO
50 Washington, DC Dr. Blanca Escribano Advisor, Malaria Elimination, PAHO
51 Washington, DC Dr. Rainier Escalada Advisor on Policies, Advocacy and Malaria Capacity Building, PAHO
52 Washington, DC Dr. Prabhjot Singh Specialist in Malaria Surveillance, PAHO
53 Washington, DC Mr. Eric Ndofor PAHO Consultant
54 Washington, DC Ms. Janina Chavez Administrative Assistant, PAHO