Number of districts and <i>corregimientos</i> (centroids) per province or <i>comarca</i> in Panama.

<p>Number of districts and <i>corregimientos</i> (centroids) per province or <i>comarca</i> in Panama.</p

Epidemic and Non-Epidemic Hot Spots of Malaria Transmission Occur in Indigenous <i>Comarcas</i> of Panama

<div><p>From 2002–2005, Panama experienced a malaria epidemic that has been associated with El Niño Southern Oscillation weather patterns, decreased funding for malaria control, and landscape modification. Case numbers quickly decreased afterward, and Panama is now in the pre-elimination stage of malaria eradication. To achieve this new goal, the characterization of epidemiological risk factors, foci of transmission, and important anopheline vectors is needed. Of the 24,681 reported cases in these analyses (2000–2014), ~62% occurred in epidemic years and ~44% in indigenous <i>comarcas</i> (5.9% of Panama’s population). Sub-analyses comparing overall numbers of cases in epidemic and non-epidemic years identified females, <i>comarcas</i> and some 5-year age categories as those disproportionately affected by malaria during epidemic years. Annual parasites indices (APIs; number of cases per 1,000 persons) for <i>Plasmodium vivax</i> were higher in <i>comarcas</i> compared to provinces for all study years, though <i>P</i>. <i>falciparum</i> APIs were only higher in <i>comarcas</i> during epidemic years. Interestingly, two <i>comarcas</i> report increasing numbers of cases annually, despite national annual decreases. Inclusion of these <i>comarcas</i> within identified foci of malaria transmission confirmed their roles in continued transmission. Comparison of species distribution models for two important anophelines with <i>Plasmodium</i> case distribution suggest <i>An</i>. <i>albimanus</i> is the primary malaria vector in Panama, confirmed by identification of nine <i>P</i>. <i>vivax</i>-infected specimen pools. Future malaria eradication strategies in Panama should focus on indigenous <i>comarcas</i> and include both active surveillance for cases and comprehensive anopheline vector surveys.</p></div

Total frequency of cluster occurrence for <i>Plasmodium vivax</i> and <i>P</i>. <i>falciparum</i> in Panama.

<p><i>Corregimientos</i> are colored by the frequency at which they were identified by both hot spot detection methods over the designated period. <b>A</b>) <i>P</i>. <i>vivax</i> cluster frequency by <i>corregimiento</i> in epidemic years (2002–2005; maximum frequency = 8). <b>B</b>) <i>P</i>. <i>falciparum</i> cluster frequency by <i>corregimiento</i> in epidemic years (2002–2005; maximum frequency = 8). <b>C</b>) <i>P</i>. <i>vivax</i> cluster frequency by <i>corregimiento</i> in non-epidemic years (2000–2001, 2006–2014; maximum frequency = 22). <b>D</b>) <i>P</i>. <i>falciparum</i> cluster frequency by <i>corregimiento</i> in non-epidemic years (2000–2001, 2006–2010; maximum frequency = 14). Frequencies were calculated using data shown in <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0004718#pntd.0004718.s002" target="_blank">S1</a> and <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0004718#pntd.0004718.s003" target="_blank">S2</a> Figs. Panama GIS shapefile obtained from STRI [<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0004718#pntd.0004718.ref030" target="_blank">30</a>].</p

<i>Anopheles</i> mosquito specimens collected throughout Panama, for <i>Plasmodium</i> testing (Fig 1).

<p><i>Anopheles</i> mosquito specimens collected throughout Panama, for <i>Plasmodium</i> testing (<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0004718#pntd.0004718.g001" target="_blank">Fig 1</a>).</p

Comparison of predicted <i>Anopheles albimanus</i> and <i>An</i>. <i>punctimacula s</i>.<i>l</i>. distributions together with the distributions of <i>Plasmodium vivax</i> and <i>P</i>. <i>falciparum</i> cases in Panama.

<p>Comparison of predicted <i>Anopheles albimanus</i> and <i>An</i>. <i>punctimacula s</i>.<i>l</i>. distributions together with the distributions of <i>Plasmodium vivax</i> and <i>P</i>. <i>falciparum</i> cases in Panama.</p

Basic characteristics of malaria cases in Panama during non-epidemic and epidemic years (2000–2014).

<p>Basic characteristics of malaria cases in Panama during non-epidemic and epidemic years (2000–2014).</p

Map of Panama, depicting anopheline collection sites, provinces, and <i>comarcas</i>.

<p>2006–2007 collection sites = black circles; 2008–2015 collection sites = grey squares; provinces = white; <i>comarcas</i> = grey. Yellow star indicates location of Panama City. Each province and <i>comarca</i> is labeled. BOC = Bocas del Toro; CHI = Chirquí, CNB = Comarca Ngöbe-Buglé, VER = Veraguas; HER = Herrera; LST = Los Santos; COC = Coclé, COL = Colón; PAN = Panamá, CKY = Comarca Kuna Yala; CKM = Comarca Kuna de Madungandí; CKW = Comarca Kuna de Wargandí, CEM = Comarca Embera-Wounaan; DAR = Darién. CKM is a territory within PAN province; CKW is a territory within DAR province. Insets depict details in northern BOC and in southwestern DAR provinces. Panama GIS shapefile obtained from STRI [<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0004718#pntd.0004718.ref030" target="_blank">30</a>].</p

Species distribution models.

<p><b>A</b> and <b>C</b>) <i>Anopheles albimanus</i> and <b>B</b> and <b>D</b>) <i>Anopheles punctimacula s</i>.<i>l</i>. in Panama. Panels <b>A</b> and <b>B</b> represent the full extent of the species distribution models. Panels <b>C</b> and <b>D</b> represent the distributions of each species within Panama. Color shading indicates areas of predicted suitable habitat/presence of the species; white indicates areas of predicted absence of the species. Central and South American GIS shapefiles freely available from DIVA-GIS [<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0004718#pntd.0004718.ref074" target="_blank">74</a>]. Panama GIS shapefile obtained from STRI [<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0004718#pntd.0004718.ref030" target="_blank">30</a>].</p

Number of cases of <i>Plasmodium vivax</i> and <i>Plasmodium falciparum</i> in the provinces and <i>comarcas</i> of Panama by year.

<p>Grey lines = <i>comarcas</i>; black lines = provinces; solid lines = <i>P</i>. <i>vivax</i>; dashed lines = <i>P</i>. <i>falciparum</i>.</p

Annual Parasite Index (API) per year and location.

<p>Provinces = black dashed lines; <i>comarcas</i> = grey solid lines. <b>A</b> and <b>C</b>) <i>Plasmodium vivax</i> and <i>P</i>. <i>falciparum</i>, respectively, with provinces and <i>comarcas</i> grouped; <b>B</b> and <b>D</b>) <i>P</i>. <i>vivax</i> and <i>P</i>. <i>falciparum</i>, respectively, with provinces and <i>comarcas</i> separated. Note different y-axis scales on each panel. CNB = Comarca Ngöbe-Buglé, CKW = Comarca Kuna de Wargandí, CKM = Comarca Kuna de Madungandí, CKY = Comarca Kuna Yala, CEM = Comarca Emberá-Wounaan, DAR = Darién province.</p