COUNTRY BRIEFING
Eliminating malaria in
NICARAGUA
Nicaragua has experienced a 96 percent decrease in reported cases since 2000
and is implementing a spatially progressive strategy to achieve national elimination.
Overview
Nicaragua has experienced a 96 percent decrease in reported malaria cases between 2000 and 2011, from 23,878
cases to only 925 cases.1 Malaria transmission in Nicaragua is
primarily Plasmodium vivax; in 2011, 84 percent of cases were
P. vivax and the remaining 16 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. pseudopunctipennis 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 reported 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 municipalities in Nicaragua, 55 percent are categorized as low risk
and 45 percent as near-zero risk with sporadic local malaria
cases.5 In 2011, of the total population in Nicaragua, only one
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 Elimination
During 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 progressively declined, however, overall incidence remained high.8
AUGUST 2013
At a Glance1
925 Reported cases of malaria
(84% P. vivax)
0 Deaths from malaria
50 % of population at risk
(total population: 5.9 million)
0.16 Annual parasite incidence
(cases/1,000 total population/year)
0.2 % Slide positivity rate
Source: World Health Organization, World Malaria Report 2012
In accordance with the World Health Organization’s Global
Malaria Eradication Program, Nicaragua set a goal in 1959
to eliminate malaria.9 IRS using DDT reduced malaria cases
by more than 50 percent over the next few years. However,
with the development of insecticide resistance the program
scaled back its spraying efforts and cases resurged, causing
the program 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 incidence 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
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COUNTRY BRIEFING
Eliminating malaria in the NICARAGUA
Malaria Transmission Limits
Plasmodium falciparum
0
100
200
Plasmodium vivax
300
400 Kilometres
0
100
200
300
Water
Water
P. falciparum free
P. vivax free
Unstable transmission (API <0.1)
Unstable transmission (API <0.1)
Stable transmission (≥0.1 API)
Stable transmission (≥0.1 API)
400 Kilometres
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.
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, many of its goals
to improve disease control through case management,
vector control, and early detection of epidemics were not
formally adopted until 1996, when total cases reached more
than 75,000 nationally.11 The city of Managua adopted a comprehensive strategy of draining of breeding sites, biological
control of vectors in the breeding sites based on exhaustive
sampling, insecticide aerosol application based on monitor-
AUGUST 2013
ing of mosquito adults, and thorough case management by
the local health centers, and malaria cases decreased from
almost 20,000 in 1996 to nearly 1,500 by 2000.11 Over the next
few years, this malaria control strategy was implemented
across Nicaragua and reduced the total caseload by 71
percent, from 75,000 to less than 22,000.11 In 2003, as malaria
case totals continued to decrease, Nicaragua received a
Global Fund Round 2 grant with the objectives of reducing
transmission 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
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COUNTRY BRIEFING
Eliminating malaria in the NICARAGUA
Reported Malaria Cases
80,000
Number of cases
70,000
60,000
50,000
40,000
30,000
20,000
762 610 692 925
cases cases cases cases
10,000
0
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
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 2012
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
plan for malaria to be implemented through 2010. The objectives of the plan included malaria prevention, surveillance,
cost-effective vector management, early diagnosis and treatment, 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
alternatives to DDT.13 The focus of Nicaragua’s Global Fund
Round 7 grant in 2007 was on control in 117 municipalities,
which represented 76 percent of the total municipalities and
covered 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-elimination in 37 municipalities (24 percent of the total
municipalities), 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
AUGUST 2013
Eligibility for External Funding15–17
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
Economic Indicators18
GNI per capita (US$)
$1,510
Country income classification
Lower middle
Total health expenditure per capita (US$)
$125
Total expenditure on health as % of GDP
10
Private health expenditure as % total
health expenditure
46
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COUNTRY BRIEFING
high risk are sufficiently covered by malaria prevention
interventions.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.
Challenges to Eliminating
Malaria
Rural-to-urban migration
Malaria 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 Since 1996, vector control in these breeding
grounds have been based on constant surveillance and use
of biological control agents Bacillus sphericus and Bacillus
thuringiensis israelensis, demonstrating the high effectiveness and efficiency of biological control of vectors.11 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
Eliminating malaria in the NICARAGUA
rural-to-urban migration, which can perpetuate the spread
malaria, is an additional incentive to improve diagnosis,
treatment, and surveillance.
Mosquito breeding grounds
While 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.
Conclusion
In 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 transmission in 37 municipalities to continue its spatially progressive strategy to achieve national elimination.7
Sources
1. WHO. World Malaria Report 2012. Geneva: World Health Organization; 2012.
2. PAHO. Health in the Americas, 2007. Volume II-Countries: Nicaragua. Pan American Health Organization, 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 Americas: 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. Pan American Health Organization, 2001.
7. Nicaragua Country Coordinating Mechanism. Round 9 Global Fund grant: stop the local transmission of malaria, focused upon pre-elimination 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. Guharay, F, Rossini, L, Zamora, N. Estrategias sostenibles para el control de la Malaria: Guía para operadores sanitarios. Ministerio de
Salud MINSA, Nicaragua y MOVIMONDO, Italia. 2000.
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. Roll Back Malaria Partnership. 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, Tuberculosis and Malaria; 2007.
AUGUST 2013
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COUNTRY BRIEFING
Eliminating malaria in the NICARAGUA
15. IDA. International Development Association Eligibility. 2013; Available from: http://web.worldbank.org/WBSITE/EXTERNAL/EXTABOUTUS/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). 2013; Available from: http://www.fightingmalaria.gov/countries/index.html.
17. The Global Fund to Fight AIDS Tuberculosis and Malaria. The Global Fund Eligibility List. 2013; Available from: http://www.theglobalfund.
org/en/application/applying/ecfp/eligibility.
18. World Bank. World Development Indicators Database. 2013; 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.
Transmission Limits Maps Sources
Guerra, 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)
About This Briefing
This 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.
Additional edits and improvements to the content of this country briefing were kindly provided by Dr. Falguni Guharay,
Consultant, Sustainable development and communication, Nicaragua.
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.
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.
GLOBAL HEALTH GROUP PROJECT TEAM
Editor: Allison Phillips | Managing Editor: Chris Cotter | Researcher and Content Developers:
Harmonie Adams and Saehee Lee | Graphic Designer: Kerstin Svendsen
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