Successful malaria elimination in the Ecuador-Peru border region: epidemiology and lessons learned

Abstract

Background: In recent years, malaria (Plasmodium vivax and Plasmodium falciparum) has been successfully controlled in the Ecuador-Peru coastal border region. The aim of this study was to document this control effort and to identify the best practices and lessons learned that are applicable to malaria control and to other vector-borne diseases. A proximal outcome evaluation was conducted of the robust elimination programme in El Oro Province, Ecuador, and the Tumbes Region, Peru. Data collection efforts included a series of workshops with local public health experts who played central roles in the elimination effort, review of epidemiological records from Ministries of Health, and a review of national policy documents. Key programmatic and external factors are identified that determined the success of this eradication effort.

Case description: From the mid 1980s until the early 2000s, the region experienced a surge in malaria transmission, which experts attributed to a combination of ineffective anti-malarial treatment, social-ecological factors (e.g., El Niño, increasing rice farming, construction of a reservoir), and political factors (e.g., reduction in resources and changes in management). In response to the malaria crisis, local public health practitioners from El Oro and Tumbes joined together in the mid-1990s to forge an unofficial binational collaboration for malaria control. Over the next 20 years, they effectively eradicated malaria in the region, by strengthening surveillance and treatment strategies, sharing of resources, operational research to inform policy, and novel interventions.

Discussion and evaluation: The binational collaboration at the operational level was the fundamental component of the successful malaria elimination programme. This unique relationship created a trusting, open environment that allowed for flexibility, rapid response, innovation and resilience in times of crisis, and ultimately a sustainable control programme. Strong community involvement, an extensive microscopy network and ongoing epidemiologic investigations at the local level were also identified as crucial programmatic strategies.

Conclusion: The results of this study provide key principles of a successful malaria elimination programme that can inform the next generation of public health professionals in the region, and serve as a guide to ongoing and future control efforts of other emerging vector borne diseases globally.

Keywords: Binational collaboration; Border region; Ecuador; Elimination; Malaria; Peru; Plasmodium falciparum; Plasmodium vivax; Vector control.

Fig. 1

a Coastal border region between Ecuador and Peru (El Oro Province and Region of Tumbes) (Google Earth, 2013). b, c and d exhibit the incidence of malaria by canton (El Oro) or district (Tumbes) in 1990, 2000, and 2010 (base map from Google Earth, 2013). Incidence is shown in El Oro for all three periods, and in Tumbes for the year 2010, when data were available

Fig. 2

Time series of monthly malaria cases and climate for El Oro and Tumbes: a monthly malaria cases (*no monthly cases available for Tumbes before 2001), b Oceanic Niño Index, 3-month running mean anomalies in sea surface temperature in the Niño 3.4 region, c El Oro mean monthly temperature (maximum and minimum) and rainfall (mm), d Tumbes mean monthly temperature (maximum and minimum) and rainfall (mm)

Fig. 3

Seasonality of malaria and climate in El Oro (1990–2012). Box plots shown with a loess smoothing function for a monthly malaria cases, b total monthly rainfall, and c mean minimum air temperature

Fig. 4

Seasonality of malaria (2001–2012) and climate in Tumbes (1990–2012). Box plots shown with a loess smoothing function for a monthly malaria cases, b total monthly rainfall, and c mean minimum air temperature

Fig. 5

a Timeline of malaria incidence in El Oro, Ecuador, (cases per 10,000 people per year) and events affecting malaria control in the Ecuador–Peru border region from 1990 to 2012. Events occurred in Ecuador except where otherwise specified. b Time series of malaria incidence in the Tumbes Region, Peru (cases per 10,000 people per year) from 1990 to 2012

Fig. 6

Photography of SNEM personnel in collaborative work on the border (SNEM archives-El Oro). a Treating flooded area with diesel. b Characterization of mosquito breeding site. c–f. Community-led, SNEM supported cleanup (“minga”) of the International Canal between El Oro and Tumbes in 2008. SNEM in Tumbes reported a 40% decline in malaria cases following the extensive cleaning of the canal (MINSA 2008. http://www.minsa.gob.pe/portada/prensa/nota_completa.asp?nota=6214)