Rev Peru Med Exp Salud Publica. 2022;39(4):463-68.

BRIEF ORIGINAL

MALARIA IN THE ECO-EPIDEMIOLOGICAL

REGION OF THE COLOMBIAN CARIBBEAN,
1960-2019
Luis Acuña-Cantillo , Mario J. Olivera
1,a 1,b
, Julio Cesar Padilla-Rodríguez 2,c

1
Instituto Nacional de Salud de Colombia, Bogotá, Colombia
2
Knowledge Management, Research and Innovation in Malaria Network, Instituto Nacional de Salud de Colombia, Bogotá,
Colombia
a
Biologist; b Physician, master in Clinical Epidemiology and Health Economics; c Physician, specialist in Public Health and
Epidemiology

ABSTRACT
Malaria has a heterogeneous and variable behavior among Colombian regions. In order to establish its
epidemiological behavior in the Colombian Caribbean region between 1960 and 2019, we carried out an
observational, descriptive and retrospective study based on records from the Ministry of Health and other
secondary sources. We defined epidemiological variables and used measures of frequency and central tendency.
A total of 155,096 cases were registered. The decades with the highest number of cases were 1990-1999 (20.5%)
and 1980-1989 (18.9%). The average number of cases per decade was 25,849.3. The highest parasite rates were
recorded in 1970 (3.3 per 1000 population) and 1981 (3.9 per 1000 population). Plasmodium vivax was the
most frequent species and most of the burden by age group was found in people under 29 years of age, between
2010-2019. Malaria showed an endemic-epidemic pattern of low and very low transmission intensity, with a
decreasing trend.
Keywords: Malaria; Epidemiology; Plasmodium vivax; Plasmodium falciparum; Caribbean; Colombia
(Source: MeSH NLM)

INTRODUCTION

In Colombia, malaria accounts for 54.7% of the cumulative burden of cases of vector-borne
diseases (1). In the last five years, there has been a change in the prevalence of the parasitic spe-
Cite as: Acuña-Cantillo L, Olivera cies in the country, with Plasmodium falciparum being the most frequent one (2,3).
MJ, Padilla-Rodríguez JC. Malaria in
This disease persists as a public health problem, imposing a high economic and social bur-
the eco-epidemiological region of the
Colombian Caribbean, 1960-2019. den (4,5). Its transmission is endemic-epidemic, heterogeneous and varies from medium to low
Rev Peru Med Exp Salud Publica.
2022;39(4):463-68. doi: https://doi. intensity in the eco-epidemiological regions throughout the national territory, under different
org/10.17843/rpmesp.2022.394.11359.
_________________________________
conditions of receptivity and vulnerability.
In the Caribbean region, the disease is confined and of very low transmission (6). In 2018, it con-
Correspondence: Luis Acuña-
Cantillo; lacuna@ins.gov.co tributed 3% of the national malaria burden, and most cases were imported from other regions with
_________________________________
varying degrees of transmission intensity (7). Despite this, few studies have been carried out on the
Received: 19/05/2022
Approved: 26/10/2022
subject in this region, which have been specific and with limited dissemination, making it difficult
Online: 05/12/2022 to make evidence-based decisions for the definition and implementation of eradication strategies (8).
The intensification of environmental, economic, social, political, and cultural interactions
in the last decade could change the transmission dynamics in the Caribbean region in the

This work is licensed under a

coming years, favoring the reemergence, continuity, and intensification of endemic-epidemic
Creative Commons Attribution 4.0 levels in the region . Therefore, the aim of this study was to identify the epidemiological
(9)
International4.0 Internacional
behavior of malaria in the Colombian Caribbean region between 1960 and 2019.

https://doi.org/10.17843/rpmesp.2022.394.11359 463
Rev Peru Med Exp Salud Publica. 2022;39(4):463-68. Malaria in the Colombian Caribbean, 1960-2019

THE STUDY
KEY MESSAGES
Design, population and study area
A descriptive study was conducted in the Colombian Cari- Motivation for the study: the information available on the
bbean region. This region is located in northern Colombia epidemiology of malaria in the Colombian Caribbean region
and is made up of the departments of Atlántico, Bolívar, is incomplete, poorly systematized and its dissemination is
Cesar, La Guajira, Magdalena, Sucre and the Archipelago of limited. This has led to a lack of knowledge of its magnitude and
San Andrés, Providencia and Santa Catalina. It has an area a low perception of its importance as a public health problem.
of 107,027 km2 and represents 9.4% of the Colombian terri- Main findings: the behavior of malaria is endemic-epidemic,
tory. The region includes 167 municipalities and has an esti- with low to very low transmission, focused and with irregular
mated population of 8,900,000 inhabitants, 22% (1,963,548 outbreaks. Plasmodium vivax infections predominate.
inhabitants) of whom are at potential risk of malaria, and
of these, 13% (260,544 inhabitants) are in areas with active Implications: the results of this study contribute to improve
transmission and presence of vectors. evidence-based decision making for the implementation of
malaria eradication plans.

Study variables and inclusion criteria

We selected and included the universe of confirmed cases
of uncomplicated malaria reported by the Departmental
Health Secretariats to the Public Health Surveillance System te index) and specific ones such as AFI (annual P. falciparum
(SIVIGILA) during the study period, as registered in the index) and AVI (annual P. vivax index): [No. cases (total or
Integrated Social Protection Information System (SISPRO) by parasite species x 1000) / (Population at risk)]. We deter-
(https://www.sispro.gov.co/Pages/Home.aspx). In addition, mined percentage distributions of cases per decade and per
secondary information from the National Malaria Program department. Finally, dispersion measures such as standard
for the period 1960-1999, available at the Ministry of Health deviation (SD), maximum and minimum values were used.
and Social Protection was included. The distribution by age group was estimated from the cu-
We used the official case definition of uncomplicated ma- mulative percentage distribution in the country during the
laria. The number of malaria cases and variables of place (de- 2010-2019 period. The coefficient of determination (R2) was
partments) and time (year, decades and period) were used. In estimated in order to establish the time trend.
Colombia, it is mandatory that all malaria cases reported to
the surveillance system be confirmed using parasitological- Ethical Aspects
diagnosis by microscopy, rapid diagnostic tests or polymerase We followed the ethical requirements established in Reso-
chain reaction. Microscopy examination is the gold standard lution 8430 of 1993 (Article 11) of the Colombian Ministry
for diagnosis of the disease in the country (8). Information on of Health and Social Protection, which defines this research
the population at risk was obtained from national census pro- as risk-free and therefore it does not require approval by an
jections of the National Administrative Department of Sta- ethics committee (10).
tistics (DANE) (http://www.dane.gov.co/) for the years 1964,
1973, 1985, 1993, 2005 and 2018, corresponding to the rural FINDINGS
population of the region. Malaria transmission intensity crite-
ria by eco-epidemiological regions were assumed according to Between 1960 and 2019, 155,096 malaria cases were registered
the classification established in a previous study (6). The Carib- in the Caribbean Region. The mean number of cases per deca-
bean region, like the other regions, is made up of departments de was 25,849.3 SD: 4,192.3). The decades 1990-1999 (31,815
and municipalities that share similar social and environmen- cases) and 1980-1989 (29,286 cases) had the highest number of
tal characteristics. cases. Among the departments, Bolivar with 43.4% (67,330 ca-
ses), La Guajira with 14.4% (22,330 cases) and Sucre with 12.1%
Data analysis (18,827 cases) contributed to the highest
The data of the variables were stored and analyzed with the burden in the region (Table 1).
Microsoft 365® Excel software. The distribution of quantita- The secular behavior of transmission in the Caribbean
tive variables was evaluated using the Kolmogorov-Smirnov Region showed a significant downward trend, with a variable
test. We constructed absolute frequency indicators such as endemic-epidemic, low-intensity pattern. P. vivax infections
total and specific cases. We calculated measures of central predominated. The most important outbreaks occurred in 1970
tendency such as mean number of cases and median accor- (API: 3.3 per 1,000 population), followed by 1981 (API: 3.9 per
ding to the distribution and measures of relative frequency 1,000 population). The coefficient of determination (R2) was
as general malariometric indices such as API (annual parasi- 0.24 (Figure 1).

464 https://doi.org/10.17843/rpmesp.2022.394.11359
Rev Peru Med Exp Salud Publica. 2022;39(4):463-68. Acuña-Cantillo L et al.

Sixty-two percent (96,072/155,096) of the registered ma- is endemic-epidemic, focalized and with low-intensity, with P.
laria cases in the region were P. vivax, except in the depart- vivax being the most frequent species. Indigenous people are the
ments of Cesar and Magdalena where P. falciparum infections most affected group, mainly those between 10 and 49 years of
predominated with 55.3% (9,574/17,328 cases) and 52.6% age. In addition, there is a permanent flow of immigrants from
(8,086/15,362 cases), respectively (Table 2). Cases were found different countries and continents that increase vulnerability (14).
in all age groups, and the most vulnerable people were those In Venezuela, a re-emergence ofmalaria transmission has been
under 29 years of age. These contributed 76% (17,802/23,517 reported in recent years, nonetheless, in the coastal states of
cases) of the cumulative burden of cases registered in the 2010- Sucre and Zulia the intensity of transmission is low, with a pre-
2019 decade. Of the latter, the 15-29 age group was the most valence of P. vivax in more than 90% of the cases, affecting the
affected with 39% (9,148/23,517) of the cases (Figure 2). economically active population (15).
In Colombia, the eco-epidemiological regions of the Pa-
DISCUSSION cific, Urabá-Bajo Cauca Sinú San Jorge and Amazonia are the
ones that contributed most to the malaria burden in the coun-
This study showed that malaria in the Caribbean region is of try between 2010-2019 (6). In the Caribbean region, active and
low transmission intensity, with a variable endemic-epidemic focal transmission has only been described in municipalities
pattern, with a significant downward trend and a predominan- in southern Bolivar and La Guajira, where occasional epide-
ce of P. vivax cases. mic outbreaks are reported. In Bolívar, transmission is explai-
The territory presents suitable conditions of receptivity and ned by the migration of susceptible populations and parasite
vulnerability for transmission, such as changes caused by de- carriers from other endemic areas in Colombia, due to social
forestation, increased number illicit crops and illegal mining, and political conflicts as well as economic interests, such as
which favor the reproduction of Anopheles vectors (11). The illegal gold mining (11). The latter has been a fundamental
described situation is similar to that observed in transmission factor in the transmission of malaria in that area, where the
scenarios in neighboring endemic countries in the Caribbean vectors An. darlingi, An. nuneztovari, and An. neomaculi-
basin. palpus (16) have been reported.
In Nicaragua, a variable endemic-epidemic pattern was des- The department of La Guajira, the northernmost depart-
cribed during the 2000-2019 period, with an initial downward ment of Colombia, is characterized by its environmental, social
trend between 2000-2007, maintaining low transmission levels and cultural complexity, which have influenced the dynamics of
until 2014, and then again showing an upward trend until 2019 vector-borne diseases. The behavior of the malaria is of low in-
with predominance of P. vivax infections (12). In Costa Rica, there tensity, with sporadic epidemic outbreaks, such as the one that
was a significant downward trend in morbidity, low transmis- occurred between December 1999 and February 2000. During
sion and predominance of P. vivax. In recent years, there has those months, there was an unusual increase in the number of
been a moderate increase in the number of cases, with nearly cases, most of which were caused by P. falciparum and affected
50% of cases being imported (13). In Panama, malaria cases are the rural indigenous population. The main recognized breeding
mostly reported in the Darien region, where the transmission sites were bodies of water, ponds, “jaguayes” and swamps for-

Table 1. Total malaria cases by decade in the Colombian Caribbean eco-epidemiological region, 1960-2019.

Decades Distribution %
Departments Total
by department
1960-1969 1970-1979 1980-1989 1990-1999 2000-2009 2010-2019

Atlantico 457 1644 1012 10 200 419 169 13,901 9,0

Bolívar 6977 8571 12 215 15 352 4016 20 199 67,330 43,4

Cesar 2045 3049 1958 784 9251 241 17,328 11,2

La Guajira 819 3334 4544 3263 8539 1 831 22,330 14,4

Magdalena 7726 2747 1908 819 1936 226 15,362 9,9

Archipiélago de San Andrés, 0 0 0 1 0 17 18 0,01
Providencia y Santa Catalina
Sucre 2030 5302 7649 1396 1616 834 18,827 12,1

Total 20 054 24 647 29 286 31 815 25 777 23 517 155,096 100

Distribución % por década 12,9 15,9 18,9 20,5 16,6 15,2 100 -

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 Rev Peru Med Exp Salud Publica. 2022;39(4):463-68. Malaria in the Colombian Caribbean, 1960-2019

5
Annual Parasitic Index (API)
4.5
Annual P. vivax index (AVI)
4 Year 1981 API: 3.9
Annual P. falciparum index (AFI)
3.5
Year 1970 API: 3.3
API per 1,000 population

2.5

1.5 y= -0.028x +1.6223

R2= 0.24
1

0.5

98
84
86
88
90
92
94

00

16
04

12
14
60
62
64
66
68
70
72
74
76
78
80
82

02

06
96

10
08

18
19
19
19
19
19
19
19

20

20
20

20
20
19
19
19
19
19
19
19
19
19
19
19
19

20

20
19

20
20

20
Years

Figure 1. Malaria behavior in the eco-epidemiological region of the Colombian Caribbean, 1960-2019.

med after the rainy season, where the immature forms of the ments in the region have adequate receptivity conditions
An.albimanus and An. triannulatus vectors breed (17). and competent Anopheles vector species are reported, there
On the other hand, the predominance of P. falciparum is no active transmission of the disease (20).
in the departments of Cesar and Magdalena may have been The main limitation of this study is the low perception of
related to the migration of people attracted by the cotton the magnitude and importance of this problem in the region
and banana agro-industrial growth between the 1940s and by those responsible of the situation, which could affect the
1960s (18), these people came from neighboring regions such availability and reliability of the information. In addition, it is
as Urabá - Bajo Cauca Sinú San Jorge and the Pacific, contri- likely that the low knowledge of health professionals in the re-
buting to the predominance of malaria due to P. falciparum. gion has an impact on the diagnosis and notification of cases,
Recently, the proliferation and exploitation of illicit crops which could lead to underreporting. On the other hand, it was
adjacent to the Sierra Nevada de Santa Marta sector and the difficult to analyze the age variable because it was not uniformly
worsening of the armed conflict have caused population dis- registered in the different information systems we used. It was
placements that explain the intensification of transmission (19). only possible to obtain this variable from the national reports of
Another relevant fact is that although the rest of the depart- the event in the last decade.

Table 2. Distribution of cumulative malaria cases by parasite species in the departments of the Colombian Caribbean eco-epidemiological region,
1960-2019.

P. falciparum P. vivax Total

Department
No. of cases % No. of cases % No. of cases
Atlantico 1366 9.8 12,535 90.2 13,901
Bolívar 23,520 34.9 43,810 65.1 67,330
Cesar 9574 55.3 7754 44.7 17,328
La Guajira 9503 42.6 12,827 57.4 22,330
Magdalena 8086 52.6 7276 47.4 15,362
Archipelago of San Andrés, Providencia y Santa Catalina 7 38.9 11 61.1 18
Sucre 6968 37.0 11,859 63.0 18,827
Total 59,024 38.0 96,072 62.0 155,096

466 https://doi.org/10.17843/rpmesp.2022.394.11359
Rev Peru Med Exp Salud Publica. 2022;39(4):463-68. Acuña-Cantillo L et al.

4000 76%*
37%** 39%***
3500

3000

2500

2000
Cases

1500

1000

500

0
<1 1a4 5a9 10 a 14 15 a 19 20 a 24 25 - 29 30 - 34 25 - 29 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 > 65
Age groups

* Cumulative burden of malaria <29 years (17,802 cases). ** Cumulative burden of malaria <14 years (8,654 cases). *** Cumulative burden of malaria 14 to 29 years
(9,148 cases). Cumulative cases in the 2010-2019 period: 23,517.

Figure 2. Distribution and percentage of malaria cases by age group, 2010-2019.

This study provided a baseline on the epidemiology of mala- dation of epidemiological intelligence and decision making;
ria in the Caribbean region. and to lead social and sectoral empowerment. Finally, basic
In conclusion, malaria in the Caribbean region has had and applied research lines should be established on clinical,
an endemic-epidemic behavior, with very low transmission epidemiological, entomological, environmental, social, pre-
intensity and with the presence of delimited foci of active vention and control measures, among others.
transmission that contribute the greatest cumulative burden
of cases in the region. Acknowledgments: the authors would like to thank the Secretaries of
We recommend developing micro-stratification studies Health of the departments of the Caribbean region and the
in municipalities with active transmission, considering the Ministry of Health and Social Protection for facilitating access to the
feasibility and viability of malaria elimination in order to information.
implement plans, programs and projects in the region. This
Author contributions: LAC and JCPR participated in the conception
will strengthen local capacity regarding the technical-opera- and design of the study, data collection and organization. LAC, MJO
tional response for the implementation of regular preventive and JCPR participated in the statistical analyses, drafting, revision and
and timely control programs. It will also strengthen conti- approval of the final version of the manuscript.
nuing medical education programs to improve knowledge
Conflicts of interest: the authors declare that they have no conflicts
and practice in order to ensure timely care of cases requiring
of interest.
diagnostic and treatment services. The development of com-
prehensive information systems is required for the consoli- Funding: the research was self-funded.

REFERENCES
1. Padilla JC, Lizarazo FE, Murillo OL, Mendigaña FA, Pachón E, Vera Available from: https://www.ins.gov.co/buscador-eventos/Paginas/
MJ. Epidemiología de las principales enfermedades transmitidas por Info-Evento.aspx.
vectores en Colombia, 1990-2016. Biomedica. 2017; 37:27–40. doi: 3. Iza Rodríguez SN, Iza Rodríguez JA, Padilla JC, Olivera MJ. Malaria
10.7705/biomedica.v37i0.3769. mortality in Colombia from 2009 to 2018: A descriptive study. Rev
2. Instituto Nacional de Salud de Colombia. Informes de Evento Ma- Soc Bras Med Trop. 2021;54:2019–22. doi: 10.1590/0037-8682-0441-
laria 2015-2019 [Internet]. Bogotá D.C; 2019 [cited 2022 Apr 10]. 2020.

https://doi.org/10.17843/rpmesp.2022.394.11359 467
Rev Peru Med Exp Salud Publica. 2022;39(4):463-68. Malaria in the Colombian Caribbean, 1960-2019

4. Padilla-Rodríguez JC, Olivera MJ, Padilla-Herrera MC. Epidemio- 12. Organización Panamericana de la Salud. Actualización Epidemiológi-
logical evolution and historical anti-malarial control initiatives in ca: Situación de la malaria en Resumen de la situación [Internet]. Was-
Colombia, 1848-2019. Infez Med. 2022;30(2):309-319. doi: 10.53854/ hington D.C: Organización Panamericana de la Salud 2020 [cited 2022
liim-3002-19. Apr 10]. Available from: https://iris.paho.org/handle/10665.2/52288.
5. Olivera MJ, Peña C, Yasnot MF, Padilla J. Socioeconomic determinants 13. Ministerio de Salud de Costa Rica. Plan de eliminación de la malaria
for malaria transmission risk in Colombia: An ecological study. Mi- en Costa Rica, 2015-2020 [Internet]. San Jose: Ministerio de Salud
crobes Infect Chemother. 2022;2:e1339. doi: 10.54034/mic.e1339. de Costa Rica; 2020 [cited 2022 Apr 10]. Available from: https://
6. Padilla JC, Olivera MJ, Ahumada-Franco ML, Paredes-Medina AE. www.ministeriodesalud.go.cr/index.php/biblioteca-de-archivos-left/
Malaria risk stratification in Colombia 2010 to 2019. PLoS One. documentos-ministerio-de-salud/vigilancia-de-la-salud/normas-pro-
2021;16(3): e0247811. doi: 10.1371/journal.pone.0247811. tocolos-guias-y-lineamientos/protocolos-vigilancia-de-la-salu-
7. Rodríguez-Morales AJ, Suárez JA, Risquez A, Villamil-Gómez WE, d/5902-protocolo-de-vigilancia-para-malaria-y-estrategia-nacio-
Paniz-Mondolfi A. Consequences of Venezuela’s massive migration nal-para-la-eliminacion-y-prevencion-del-restablecimiento-de-la-
crisis on imported malaria in Colombia, 2016-2018. Travel Med Infect transmision-de-malaria-en-costa-rica/file.
Dis. 2019. 28:98-99. doi: 10.1016/j.tmaid.2019.02.004. 14. Cáceres L, Victoria C, Ramirez JL, Jackman C, Calzada JE, Torres R.
8. World Health Organization. Meeting report of the WHO Evidence Study of the epidemiological behavior of malaria in the Darien region,
Review Group on the assessment of malariogenic potential to inform Panama. 2015-2017. PLoS One. 2019;14(11): e0224508 doi: 10.1371/
elimination strategies and plans to prevent re-establishment of mala- journal.pone.022450.
ria. Geneva, Switzerland; 2018. Available from: https://www.who.int/ 15. Cáceres JL. Malaria epidémica en Venezuela, año 2011. Bol Mal Salud
docs/default-source/malaria/mpac-documentation/mpac-april2019-ses- Amb. 2012;52(2):275–85.
sion7-report-erg-malariogenic-potential.pdf?sfvrsn=6f0b3bfd_2. 16. Cortes L. Aspectos ecológicos de Anopheles en Montecristo, Bolívar.
9. Ministerio de Salud y Protección Social. Adopción Parcial de Guía de Biomédica. 2011;31(S3):134–5. doi: 10.7705/biomedica.v31i0.474.
Práctica Clínica Diagnóstico y tratamiento de la malaria, OMS. Guía 17. Cáceres DC, De la Hoz F, Nicholls S, De Antonio R, Velandia M, Olano
para Colombia, 2022. Available from: https://www.minsalud.gov.co/ V, et al. Brote de malaria en La Guajira, 1 de diciembre de 1999 a 1 de
sites/rid/Lists/ BibliotecaDigital/RIDE/VS/PP/ET/Guia-atencion-clini- febrero de 2000. Biomédica. 2000;20(2):152–61.
ca-malaria.pdf. 18. Brungardt MP. La United Fruit Cat en Colombia. Rev Innovar.
10. Ministerio de Salud y Protección Social. Resolución 8430 de 1993 1995;(5):107–18.
[Internet]. Por la cual se establecen las normas científicas, técnicas y ad- 19. Instituto Nacional de Salud. Consecuencias del Conflicto Armado
ministrativas para la investigación en salud, Colombia 1993. [cited 2022 en Salud en Colombia 2017. [Internet]. Bogotá D.C: Observatorio
Apr 10]; Available from: https://www.minsalud.gov.co/sites/rid/Lists/ Nacional de Salud Vol. 9; 2017 [cited 2022 Apr 10]. Available from:
BibliotecaDigital/RIDE/DE/DIJ/RESOLUCION-8430-DE-1993.PDF https://www.ins.gov.co/Direcciones/ONS/publicaciones
11. Castellanos A, Chaparro-Narváez P, Morales-Plaza CD, Alzate A, Padilla 20. Pérez G, Pérez B, Mendoza DL, Blanco P. Identificación de especies
JC, Arévalo M, et al. Malaria in gold-mining areas in Colombia. Mem de Anopheles de importancia médica en el departamento de Sucre,
Inst Oswaldo Cruz. 2016;111(1):59–66. doi:10.1590/0074-02760150382. Colombia. DUAZARY. 2006;3(2):6. doi: 10.21676/2389783X.613.

468 https://doi.org/10.17843/rpmesp.2022.394.11359