Costa Rica: 'Ripe' for malaria elimination

26 July 2018

A mere mention of Costa Rica can conjure up images of tropical rainforests, beaches, volcanoes and some of the most diverse flora and fauna on the planet—a country that has placed itself squarely on the global ecotourism map. Yet there is one aspect of this Central American nation that is, perhaps, less known: its decades-long fight against malaria.

Costa Rica is one of 21 countries identified by WHO as having the potential to eliminate malaria by 2020. Its success in bringing down cases of indigenous malaria—that is, transmission of the malaria parasite within a country’s own borders—has been commendable, so much so that it has received an award from the Pan American Health Organization in recognition of the strides made. Notably, no one has died from malaria since 2009.

However, after recording three consecutive years of zero indigenous cases between 2013 and 2015, local transmission of the disease has slowly been creeping upwards: 4 cases in 2016 and 12 in 2017. Of equal concern is imported malaria: to date, 21 such cases have been detected in 2018, up from five for all of 2017.

In June 2018, the Costa Rican Ministry of Health issued a public health alert following the reporting of 10 imported malaria cases in just one week in the country’s northern region bordering malaria-endemic Nicaragua. The Ministry is working to quickly identify and treat imported cases to prevent onward transmission to local communities in high-risk zones of the country. The areas of concern are mainly agricultural sites, like banana plantations.

One such area is the canton of Matina, home to some of Costa Rica’s largest plantations that grow the yellow fruit. Situated next to a major port on the Caribbean Sea, the canton’s agricultural produce is shipped to markets worldwide, making Matina an important economic hub.

Although Matina is far from the area of the recent alert, and no cases of malaria have been reported this year, all 4 indigenous cases reported in 2016 originated from the canton, as well as 2 of the 12 indigenous cases in 2017. Health authorities are not taking any chances and are working with the canton’s fincas bananeras (banana plantations) to step up malaria surveillance activities, particularly among plantation workers and nearby communities.

As part of the WHO Framework for malaria elimination, countries like Costa Rica that are on the cusp of eliminating the disease must demonstrate that they have policies, procedures, and practices in place not only to get to zero cases but to keep their malaria-free status once granted. Recent developments in Costa Rica underscore why it is so important for malaria-eliminating countries to maintain strong vector control and surveillance systems, as well as the ability to respond to outbreaks and prevent re-establishment of malaria in the long term.

In the days following the June health alert, officials of the Área Rectora de Salud Matina, the local health authority, invited WHO to see first-hand the efforts under way to keep the plantations free of malaria and, ultimately, ensure Costa Rica stays on track to eliminate the disease by 2020.

WHO/J Ruiz Cirera
Costa Rica – a country of nearly 5 million people – is on the verge of eliminating malaria. It is one of 21 countries identified by WHO as having the potential to become malaria-free in the next few years. In 2017, Costa Rica registered only 12 indigenous and 5 imported cases of the mosquito-borne disease. Preventing outbreaks is a key area of focus in Costa Rica’s malaria elimination strategy. In the country’s Matina canton this translates into working closely with the fincas bananeras (banana plantations) to keep their workers healthy and sites malaria-free .

Costa Rica – a country of nearly 5 million people – is on the verge of eliminating malaria.

It is one of 21 countries identified by WHO as having the potential to become malaria-free in the next few years. In 2017, Costa Rica registered only 12 indigenous and 5 imported cases of the mosquito-borne disease. Preventing outbreaks is a key area of focus in Costa Rica’s malaria elimination strategy. In the country’s Matina canton this translates into working closely with the fincas bananeras (banana plantations) to keep their workers healthy and sites malaria-free .

WHO/J Ruiz Cirera

WHO/J Ruiz Cirera
Costa Rica lies in the tropics with a climate characterized by moderate heat, humidity and extended rainy seasons. While ample water is good for growing bananas, it also creates prime conditions for malaria-carrying mosquitoes. Female Anopheles mosquitoes like to breed in areas where there is clean, sunlit and still water, such as ditches and rain puddles. Banana plantation irrigation systems must have proper drainage and canalisation to prevent mosquitoes from breeding.

Costa Rica lies in the tropics with a climate characterized by moderate heat, humidity and extended rainy seasons.

While ample water is good for growing bananas, it also creates prime conditions for malaria-carrying mosquitoes. Female Anopheles mosquitoes like to breed in areas where there is clean, sunlit and still water, such as ditches and rain puddles. Banana plantation irrigation systems must have proper drainage and canalisation to prevent mosquitoes from breeding.

WHO/J Ruiz Cirera

WHO/J Ruiz Cirera
The day starts early on the plantations in Matina, with most workers beginning their shifts at dawn. Mosquitoes that transmit malaria are often most active at dusk, at night and during morning hours, before it becomes too hot. It is important to know when and where mosquitoes bite to ensure workers and communities are protected.

The day starts early on the plantations in Matina, with most workers beginning their shifts at dawn.

Mosquitoes that transmit malaria are often most active at dusk, at night and during morning hours, before it becomes too hot. It is important to know when and where mosquitoes bite to ensure workers and communities are protected.

WHO/J Ruiz Cirera

WHO/J Ruiz Cirera
This finca bananera in Matina has 1600 banana trees spread out over 3.6 km2 of land. Each tree produces an average of 15 kg of bananas per year. Some 330 people work on the plantation, split between the fields and the packaging facility. Most workers live on the grounds of the plantations in lodgings called baches.

This finca bananera in Matina has 1600 banana trees spread out over 3.6 km2 of land.

Each tree produces an average of 15 kg of bananas per year. Some 330 people work on the plantation, split between the fields and the packaging facility. Most workers live on the grounds of the plantations in lodgings called baches.

WHO/J Ruiz Cirera

WHO/J Ruiz Cirera
Of the 55 male workers at this bache, the majority are in their early 20s to mid 30s, and many are from other countries in the Americas, like Ecuador and Nicaragua. Because of the close quarters, the Costa Rican Ministry of Health works with the owners of the fincas bananeras to promote living conditions that prevent the spreading of diseases like tuberculosis and those carried by mosquitoes and other animals such as bats and rodents. To protect workers against malaria, the indoor walls and ceilings of the baches are sprayed with an effective dose of insecticide. This technique – known as indoor residual spraying, or IRS – is one of several malaria prevention approaches recommended by WHO.

Of the 55 male workers at this bache, the majority are in their early 20s to mid 30s, and many are from other countries in the Americas, like Ecuador and Nicaragua.

Because of the close quarters, the Costa Rican Ministry of Health works with the owners of the fincas bananeras to promote living conditions that prevent the spreading of diseases like tuberculosis and those carried by mosquitoes and other animals such as bats and rodents. To protect workers against malaria, the indoor walls and ceilings of the baches are sprayed with an effective dose of insecticide. This technique – known as indoor residual spraying, or IRS – is one of several malaria prevention approaches recommended by WHO.

WHO/J Ruiz Cirera

WHO/J Ruiz Cirera
Gisela Fernández Mora (left) and Fabiana Hernández Gutiérrez (right) are inspectors with the Costa Rican Ministry of Health. Their job takes them to baches throughout Matina canton to conduct routine health surveys. They ask the plantation workers about their overall state of health and if they are experiencing any symptoms that could indicate a viral or parasitic infection or underlying health condition. The Government of Costa Rica provides free universal access to malaria prevention, diagnosis and treatment for all people—a key pillar of the WHO Global Technical Strategy for Malaria 2016-2030.

Gisela Fernández Mora (left) and Fabiana Hernández Gutiérrez (right) are inspectors with the Costa Rican Ministry of Health.

Their job takes them to baches throughout Matina canton to conduct routine health surveys. They ask the plantation workers about their overall state of health and if they are experiencing any symptoms that could indicate a viral or parasitic infection or underlying health condition. The Government of Costa Rica provides free universal access to malaria prevention, diagnosis and treatment for all people—a key pillar of the WHO Global Technical Strategy for Malaria 2016-2030.

WHO/J Ruiz Cirera

WHO/J Ruiz Cirera
Fabiana and Gisela ask the workers if they are experiencing fever, headache, muscle or joint pain, nausea, vomiting, diarrhoea, fatigue or any other symptoms that could point to chikungunya, dengue, or malaria. Health inspectors play an important role in carrying out the government of Costa Rica’s malaria elimination plan by conducting vital surveillance activities among people most at risk of the disease.

Fabiana and Gisela ask the workers if they are experiencing fever, headache, muscle or joint pain, nausea, vomiting, diarrhoea, fatigue or any other symptoms that could point to chikungunya, dengue, or malaria.

Health inspectors play an important role in carrying out the government of Costa Rica’s malaria elimination plan by conducting vital surveillance activities among people most at risk of the disease.

WHO/J Ruiz Cirera

WHO/J Ruiz Cirera
Near the banana plantation is Estrada, a small town of about 100 homes, a school and a supermarket. Berny Reyes Rodriguez is a vector control inspector with the Ministry of Health, based out of Matina’s central health authority, Área Rectora de Salud de Matina. He spends a good part of his day in communities like Estrada to seek out bodies of water that are known to be habitats for mosquito larvae. Identifying such sites is highly dependent on local knowledge, and inspectors like Berny work with community members to locate them. He uses a large metal dipper, or cucharoneo, to check the water for mosquito larvae.

Near the banana plantation is Estrada, a small town of about 100 homes, a school and a supermarket.

Berny Reyes Rodriguez is a vector control inspector with the Ministry of Health, based out of Matina’s central health authority, Área Rectora de Salud de Matina. He spends a good part of his day in communities like Estrada to seek out bodies of water that are known to be habitats for mosquito larvae. Identifying such sites is highly dependent on local knowledge, and inspectors like Berny work with community members to locate them. He uses a large metal dipper, or cucharoneo, to check the water for mosquito larvae.

WHO/J Ruiz Cirera

WHO/J Ruiz Cirera
As a vector control specialist, Berny is especially on the lookout for the larvae of the Anopheles mosquito; only females of this species carry the malaria parasite. He quickly recognizes that the larvae he found belongs to a Culex mosquito, not the kind related to malaria. Monitoring of mosquito habitats is one component of effective malaria surveillance and control activities. In March 2018, WHO released a new reference manual on malaria surveillance, monitoring & evaluation to support countries in strengthening their surveillance activities, which is applicable even in malaria-eliminating countries like Costa Rica.

As a vector control specialist, Berny is especially on the lookout for the larvae of the Anopheles mosquito; only females of this species carry the malaria parasite.

He quickly recognizes that the larvae he found belongs to a Culex mosquito, not the kind related to malaria. Monitoring of mosquito habitats is one component of effective malaria surveillance and control activities. In March 2018, WHO released a new reference manual on malaria surveillance, monitoring & evaluation to support countries in strengthening their surveillance activities, which is applicable even in malaria-eliminating countries like Costa Rica.

WHO/J Ruiz Cirera

WHO/J Ruiz Cirera
At a roadside restaurant midway between the banana plantation and Estrada, health inspector Julio Reyes Gutiérrez is sent to draw a blood sample from a young a female worker who reports a fever. Julio will take the sample back to the local hospital so that a microscopy test can be performed to check for malaria.

At a roadside restaurant midway between the banana plantation and Estrada, health inspector Julio Reyes Gutiérrez is sent to draw a blood sample from a young a female worker who reports a fever.

Julio will take the sample back to the local hospital so that a microscopy test can be performed to check for malaria.

WHO/J Ruiz Cirera

WHO/J Ruiz Cirera
Following a malaria outbreak in the canton of Matina in 2016 and early 2017 (when 6 indigenous cases of malaria were reported in the town of Saborío) and the June 2018 public health alert in northern Costa Rica, officials in Matina are not taking any chances and are stepping up diagnostic testing activities. WHO recommends prompt malaria diagnosis either by microscopy or malaria rapid diagnostic test for all patients with suspected malaria before treatment is administered.

Malaria outbreak in the canton of Matina in 2016 and early 2017

Following a malaria outbreak in the canton of Matina in 2016 and early 2017 (when 6 indigenous cases of malaria were reported in the town of Saborío) and the June 2018 public health alert in northern Costa Rica, officials in Matina are not taking any chances and are stepping up diagnostic testing activities. WHO recommends prompt malaria diagnosis either by microscopy or malaria rapid diagnostic test for all patients with suspected malaria before treatment is administered.

WHO/J Ruiz Cirera

WHO/J Ruiz Cirera
Health inspector Julio needs just enough blood from the young woman to prepare two blood smears on the glass slide: one thin, one thick. Back at the main hospital in Matina, a laboratory technician will examine the blood using a microscope to look for parasites. Costa Rica’s strong health system means that early and accurate diagnosis of malaria is possible.

Health inspector Julio needs just enough blood from the young woman to prepare two blood smears on the glass slide: one thin, one thick.

Back at the main hospital in Matina, a laboratory technician will examine the blood using a microscope to look for parasites. Costa Rica’s strong health system means that early and accurate diagnosis of malaria is possible.

WHO/J Ruiz Cirera

WHO/J Ruiz Cirera
Yo me apunto – ‘I’m in’ to defeat malaria, announces a billboard at an elementary school on the outskirts of Matina. In 2017, Costa Rica reported 12 indigenous cases of malaria, including 2 in Matina canton. To date, no indigenous cases of the disease have been reported across the country in 2018. However, the risk of malaria transmission remains a real threat to Costa Rica’s elimination ambitions. While the country is ripe to reach malaria-free status, continued vigilance and sharp focus will be required to clear out malaria, once and for all.

Yo me apunto – ‘I’m in’ to defeat malaria, announces a billboard at an elementary school on the outskirts of Matina.

In 2017, Costa Rica reported 12 indigenous cases of malaria, including 2 in Matina canton. To date, no indigenous cases of the disease have been reported across the country in 2018. However, the risk of malaria transmission remains a real threat to Costa Rica’s elimination ambitions. While the country is ripe to reach malaria-free status, continued vigilance and sharp focus will be required to clear out malaria, once and for all.

WHO/J Ruiz Cirera

Global Malaria Programme

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