BOLIVIA

1. BOLIVIA BOLIVIA 1.098.581 Km2 de Superficie 8.137.113 Habitantes, 57.5% Urbano 9 Departamentos 112 Provincias 314 Secciones Municipales USAID/Bolivia

2. USAID Infectious Diseases Strategy • Understand, contain and respond to the development and spread of AMR (antimicrobial resistance) • Reduce the incidence of tuberculosis among key populations • Reduce deaths due to malaria • Improve the capacity to obtain and use good quality data for surveillance and effective response USAID/Bolivia

3. USAID/BoliviaInfectious Diseases InitiativeFY1998 - 2002 • Goal: To support decentralized and participatory health care systems; improved quality and increased coverage of community health care by local governments and PVOs/NGOs; and improved child survival, reproductive and sexual health practices. USAID/Bolivia

4. Objective I. • To develop capacity for implementing innovative and sustainable community-based prevention and control programs for priority infectious diseases (Chagas disease, tuberculosis, & malaria) in highly endemic areas of Bolivia, via local governments and NGOs. USAID/Bolivia

5. Objective II. • To strengthen the Epidemiological Surveillance System for Infectious Diseases to increase Quality and Coverage of Local Health Services via: • enabling the MOH to develop and strengthen a decentralized epidemiological surveillance system for infectious diseases in coordination with regional centers for vectorborne/infectious diseases. • support MOH in developing intra-regional, cross-border linkages for addressing long-term prevention and control of priority infectious diseases. USAID/Bolivia

6. Objective III. • To strengthen capacity of National Laboratory Network for improved diagnosis, prevention, control, and epidemiological surveillance of priority IDs via: • developing decentralized capacity of MOH/regional centers for infectious diseases to provide technical guidance and training on infectious disease prevention and control, and epidemiological surveillance. • assisting MOH/regional centers to develop and field test new approaches and technologies for diagnosis, surveillance, AMR assessment, and the prevention/ control of priority infectious diseases. USAID/Bolivia

7. Collaborating Partners: • Ministry of Health/Bolivia: (Bilateral Agreements:PROSIN) • National Laboratory Network • NGO Network: PROCOSI • Pan American Health Organization (PAHO-WHO) • Donor Agencies: Belgium, DIFID, France/IRD, Inter-American Development Bank, World Bank • Cooperating Agencies/Institutions: CDC, NAMRID, EHP, QAP, IUATLD, MSH, NIH/Peru, UTMB, USAID/Peru, USAID/Brazil USAID/Bolivia

8. Interventions by Sector:Tuberculosis • Development of intensive DOTS initiative in 2 periurban areas of high endemicity (Santa Cruz/El Alto) – joint effort between public and private NGO sectors • Development of TB initiative in rural areas thru NGO network • Development/Consolidation of national IEC program via Bolivian IEC Institution. • Development of Spanish version of interactive training program on tuberculosis case management (DOTS). USAID/Bolivia

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10. Notified cases of Tuberculosis in LAC Region, 1994 USAID/Bolivia

11. MAPA DE RIESGO TASA DE INCIDENCIA BAAR(+) > 80 RIESGO MUY SEVERO 60-80 RIESGO SEVERO < 60 RIESGO MODERADO USAID/Bolivia

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13. Malaria • Development of national malaria strategy based on Global Malaria Strategy and Roll Back Malaria Program. • Development of national treatment protocols based on results of scientifically sound malaria drug efficacy trials. • Field-testing of rapid diagnostic assays with plans for integration with local diagnostic services in areas of Bolivian amazon. • Training/IEC for health care providers / communities to improve prompt case management of malaria via IMCI and pathway to survival. • Develop integrated prevention and control program in Bolivian Amazon among local public health sector, NGOs, and communities. USAID/Bolivia

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15. Chagas Disease • Development of household improvement via local materials/technologies • Development of BCC /IEC modules for community-based prevention interventions • Integration of efforts among NGO network, Min. of Housing and Min. of Health • Integration of Chagas disease into IMCI. USAID/Bolivia

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21. Leishmaniasis • Provide support and technical assistance for diagnosis and treatment of cutaneous/muco-cutaneous leishmaniasis in endemic areas. • Develop a referral center for leishmaniasis via an integrated USAID initiative for the Yungas. USAID/Bolivia

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24. Yellow Fever, Dengue, Emerging Diseases • Development of long term national strategies on prevention and control of yellow fever and dengue • Initiation of research to determine susceptibility of Bolivian strains of Aedes egypti to YF virus (genotype 2), and transmissibility to animal model. • Adaptation of protocols for syndromic management of YF. • Integration of hemorrhagic fevers into IMCI. • Support to MOH for outbreak investigations for emerging infectious diseases USAID/Bolivia

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27. STDs/HIV-AIDS • Technical assistance to strengthen national epidemiological surveillance for STDs/HIV-AIDS. • Strengthening of coordination of prevention efforts in border towns. • Consolidation of national IEC program via local NGO. USAID/Bolivia

28. National Immunization Program (PAI) • Support regional program for elimination of measles in the Americas. • Integration of pentavalent vaccine into PAI2. • Integration of PAI and IMCI programs to increase coverage opportunities. • Strengthened coordination between public sector and private sector NGOs to increase vaccination rates in low-coverage rural areas. USAID/Bolivia

29. Epidemiological Surveillance • To develop capacity of MOH/regional centers for infectious diseases to provide technical guidance and training on infectious diseases prevention, control, diagnosis and epidemiological surveillance. • Strengthening of laboratory network at district level in priority areas and national capacity to determine levels of antimicrobial resistance. • Strengthening of capacity at local level to implement the national epidemiological surveillance system. • Technical assistance to MOH (by CDC) to assess the integration of the epidemiological surveillance system with the NHIS USAID/Bolivia

30. Highlights:Epidemiologic Shield Program • Promoted formation of Inter-Agency Committee in September 2000. Led to strengthened coordination among donors and GOB on immunization, malaria, tuberculosis, Chagas and other infectious diseases, and epidemiological surveillance. • Strengthening of regional (and South-South) cooperation among Boliva, Brazil, and Peru (over 15 significant regional activities executed since 1999 – to be described in separate presentation). USAID/Bolivia

31. Highlights: Immunization • Support for successful elimination of measles outbreak in 1999 • Evaluation of national program led to improved management of cold chain, integration with IMCI program • Successful integration of pentavalent vaccine into national program in 2000. • Strengthened coordination between public sector and private sector NGOs. USAID/Bolivia

32. Highlights: Tuberculosis • Consolidation of national IEC program via local NGO (in progress) • Development of inter-agency committee on tuberculosis (in progress) • Development of interactive training program on DOTS (tuberculosis case management) (done - to be demonstrated in separate presentation) • Development of intensive DOTS initiative in 2 periurban areas of high endemicity (Santa Cruz/El Alto) – joint effort between public and private NGO sectors (underway) • Development of TB initiative in rural areas thru NGO network (underway) • Economic impact and mortality studies on tuberculosis (planned via PAHO) USAID/Bolivia

33. Highlights: Malaria • Development of national malaria strategy based on WHO Global Malaria Strategy and Roll Back Malaria Program (monograph). July 2000. • Development of capacity to conduct malaria drug efficacy trials (in order to establish appropriate treatment protocols and national norms) 2000/2001. • Field-testing of rapid diagnostic assays with plans for integration with local diagnostic services in areas of Bolivian amazon. (2000/2001) To be published in peer review literature. • Integration of malaria into IMCI (planned) • Integration of private and public sector programs in Bolivian amazon (model chosen to be presented at World Bank/WHO Global conference on strengthening Roll Back Malaria). • Economic impact study on malaria (planned). • Support via LAC AMR initiative for resident PAHO malariologist/advisor assigned to national malaria program. USAID/Bolivia

34. Highlights:Yellow Fever • Coordinated international conference on yellow fever in 2000 toward development of long term national strategy on prevention and control of yellow fever (monograph of scientific/technical articles published). • Supported emergency procurement of YF vaccines in response to outbreak in 2000. • Initiation of research to determine susceptibility of Bolivian strains of Aedes egypti to YF virus (genotype 2), and transmissibility to animal model. Results could enhance sustainability of national program. • Adaptation of protocols on syndromic management of YF. USAID/Bolivia

35. Highlights: Dengue and Emerging Diseases • Provided technical assistance to assess the national dengue program in 2000. • Supported source reduction campaign during periurban outbreaks in 2000. • Support to MOH for outbreak investigations for emerging infectious diseases (on-going) USAID/Bolivia

36. Highlights: Leishmaniasis • Provide support and technical assistance for diagnosis and treatment of cutaneous/muco-cutaneous leishmaniasis in endemic areas (in progess). • Development of a referral center for leishmaniasis via an integrated USAID initiative for the Yungas (planned). USAID/Bolivia

37. Highlights: STDs/HIV-AIDS • Technical assistance to strengthen national epidemiological surveillance for STDs/HIV-AIDS. • Strengthening of coordination of prevention efforts in border towns (in progress). • Consolidation of national IEC program via local NGO (in progress) USAID/Bolivia

38. Highlights: Epidemiological Surveillance • Strengthening of laboratory network at district level in priority areas (Beni, Pando, La Paz departments (in progress) • Feasibility study undertaken in 2000 for development of a vector-borne diseases center in Bolivian Amazon to strengthen the laboratory network, epidemiological surveillance, and local capacity in medical entomology. (Completed – final report under review with MOH). USAID/Bolivia

39. Highlights: Laboratory Network/Medical Entomology • Supported development of national model for epidemiological surveillance (in coordination with PAHO and IDB) in 2000. • Supported evaluation of epidemiological training course for district-level personnel in coordination with CDC, PAHO, and IDB. (In progress). • Technical assistance for computerization of epidemiological surveillance data and development of website for the Epidemiological Shield Program (planned). USAID/Bolivia

40. Highlights: National Health Information System • Technical assistance to MOH (by CDC) to assess the integration of the epidemiological surveillance system with the NHIS (planned) • Supported the first evaluation of the NHIS in 2000 in coordination with MOH, PAHO and cooperating agencies. Recommendations (if followed) should enable successful deployment of revised system, enhance training and supervision, thus also improving overall data quality. USAID/Bolivia

41. Challenges • Lack of leadership and consensus within MOH towards shaping and implementing a rational and consistent strategic agenda (e.g. health sector reform (municipalization/decentralization), RRHH, quality of services, etc.) • Politicization of national health services. • National elections in 2002 may distract from achieving program goals and objectives. USAID/Bolivia

42. Challenges • Need for more continuous coordination both within the MOH, but also among donors. Still no rational plan by MOH for strengthening coordination with NGOs. • Scarcity of human resources in MOH in such critical areas as medical entomology, epidemiology, malaria and other infectious diseases, strategic planning, health economics, etc. • Lack of progressive national policies on importation of essential drugs, mosquito nets, insecticides, and review processes related to medical research. USAID/Bolivia

43. Why we are here ... USAID/Bolivia

44. I. general background info: World Health Organization, Division for Control of Tropical Disease: http://www.who.int/ctd/ Pan American Health Organization (Organización Panamericana de la Salud) (PAHO/OPS): http://www.paho.org/ USAID’s Environmental Health Project (EHP): http://www.access.digex.net/~ehp/webliog.html CDC, Health Information for International Travelers: http://www.cdc.gov/travel/blusheet.htm Useful WEBLinks on Infectious Diseases in the Americas USAID/Bolivia

45. Acute Respiratiory Infections (Spanish): http://www.paho.org/spanish/hcp/hctari01.htm#informacion AIDS/STDs: http://www.paho.org/english/aid/aidprog.htm http://lucas.funsalud.org.mx/sidalac/english.htm http://www.paho.org/english/aid/aidw0497.htm Chagas Disease: http://www.who.int/ctd/html/chag.html Cholera: http://www.paho.org/english/hcp/hctcho02.htm ; http://www.cdc.gov/travel/cholera.htm ; http://www.who.int/chd/pub/cholera/cholemer.htm Basic facts for travelers: http://www.who.int/chd/pub/cholera/chobfact.htm II. Specific Diseases USAID/Bolivia

46. Malaria: http://www.who.int/ctd/html/malaria.html ; http://www.who.int/ctd/html/malariaburtre.html ; http://www.azer.com/AIWeb/Categories/Magazinehtml/52.folder/52.articles/52.malaria.html Malaria Risk/Treatment Regimen by Country: (CDC): http://www.cdc.gov/ncidod/dpd/malaria/tropsam.htm ; http://www.who.int/ctd/html/malariageo.html Leishmaniasis: http://www.who.int/ctd/html/leisburtre.html Arboviruses: Dengue & Yellow Fever http://www.who.int/ctd/html/dengueburtre.html ; http://www.cdc.gov/travel/yfever.htm USAID/Bolivia

47. Tuberculosis:http://www.paho.org/english/hcp/hcttb02.htm#burdenTuberculosis:http://www.paho.org/english/hcp/hcttb02.htm#burden Antimicrobial Resistance: http://www.cdc.gov/ncidod/dbmd/antibioticresistance/Default.htm Regional Emerging Infectious Diseases: http://www.paho.org/english/hcp/hcteme02.htm#americas Other insect-borne diseases: http://www.cdc.gov/travel/insctdis.htm USAID/Bolivia

48. http://www.cdc.gov/ncidod/publications/slides/index042.htm Dr. Robert S. Desowitz.Who Gave Pinta to the Santa Maria? Tracking the Devastating Spread of Lethal Tropical Disease in the Americas, W. W. Norton, 1997. Dr. Robert S. Desowitz. New Guinea Tapeworms and Jewish Grandmothers, Tales of Parasites and People, W. W. Norton, 1981. Dr. Robert S. DesowitzThe Malaria Capers, Parasites and People, Research and Reality, W. W. Norton, 1991. III. Selected Readings on Emerging Diseases USAID/Bolivia

49. Integrated Management of Childhood Illnesses (IMCI/AEPI): http://www.paho.org/english/hcp/imci/index.htm CDC Travel Information: http://www.cdc.gov/travel/index.htm Mexico & Central America: http://www.cdc.gov/travel/camerica.htm Caribbean: http://www.cdc.gov/travel/caribean.htm Tropical South America: http://www.cdc.gov/travel/tropsam.htm Temperate South America: http://www.cdc.gov/travel/temsam.htm IV. Prevention USAID/Bolivia

50. Bednets, Insecticides & Repellents: http://www.magellans.com CDC Prevention Strategy on Emerging Infectious Diseases: http://www.cdc.gov/ncidod/publications/eid_plan/home.htm National Center for Infectious Diseases: http://www.cdc.gov/ncidod/ncid.htm CDC Summary of Health Information for International Travel: http://www.cdc.gov/travel/blusheet.htm USAID’s Global Infectious Diseases Strategy: http://www.info.usaid.gov/pop_health/webid.htm USAID/Bolivia