Eliminating

Malaria
Case-study 1

Achieving elimination
in Turkmenistan
 Eliminating
Malaria
Case-study 1

Achieving elimination
in Turkmenistan
WHO Library Cataloguing-in-Publication Data

Achieving elimination in Turkmenistan.

(Eliminating malaria case-study, 1)

1.Malaria – prevention and control. 2.Malaria – epidemiology. 3.National health programs. 4.Turkmenistan I.World
Health Organization. Global Malaria Programme. II.University of California, San Francisco.

ISBN 978 92 4 150430 0 (NLM classification: WC 765)

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Contents

Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Acronyms and abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
Glossary.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Достижение элиминации малярии в Туркменистане. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix
Introduction.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
The malaria elimination case-study series.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Malaria in the WHO European Region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Malaria in Turkmenistan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Country background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Geography, population and economy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Health system and population health profile. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
History of malaria and malaria control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Parasites and vectors.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Pre-control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Initial control efforts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Initial elimination efforts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Prevention of reintroduction, 1961–1990.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Outbreaks and their control, 1991–2003.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Elimination of malaria, 2004–2010.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Prevention of reintroduction, 2010 onwards.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Factors contributing to changes in the malaria situation, 1990–2010. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Why did malaria re-emerge and an outbreak occur in the 1990s?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Why did an outbreak occur in 2002–2003?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Which populations were most affected by malaria?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Control of the 1998–1999 outbreak. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Control of the 2002–2003 outbreak. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Elimination of malaria, 2004–2010.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Cost of malaria elimination.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Lessons learned and drivers of change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Problems and constraints overcome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Comprehensive strategies applied. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Upgraded and motivated NMCP staff. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Strengthening collaboration and community mobilization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Strong political commitment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
WHO support. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Outlook for the future.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Eliminating Malaria | Achieving elimination in Turkmenistan | Contents v

Annex 1: Data sources and methods applied. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Annex 2: Demographic data from the United Nations Population Division.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Annex 3: Administrative divisions, political organization and economy.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Annex 4: Health care policies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Annex 5: Main health indicators.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Annex 6: Parasites, vectors and geographical distribution.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Annex 7: Organization of malaria control/elimination within the structures of MOHMI. . . . . . . . . . . . . . . . . . . . . . . . . . 54
Annex 8: Standard form for malaria and other communicable diseases case investigation. . . . . . . . . . . . . . . . . . . . . . . . . . 55
Annex 9: Malaria focus record form (“passport”). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

vi Eliminating Malaria | Achieving elimination in Turkmenistan | Contents

Acknowledgements

This case-study is part of a series of malaria elimination The authors would like to thank the honourable
case-studies conducted by the World Health Minister of Health, Dr Gurbanmammet Ylyasov, and
Organization (WHO) Global Malaria Programme and his staff, as well as the staff of the WHO country office
the University of California, San Francisco (UCSF), in Turkmenistan for their support and assistance in the
Global Health Group. preparation of this case-study.

The two groups wish to acknowledge the financial The authors acknowledge with thanks the contributions
support of the Bill & Melinda Gates Foundation in of the many people who participated in the collection
developing the elimination case-studies. and analysis of country information, including Professor
D. Tesler, Dr Kasim Roziev, Dr Sachli Nuriyeva, and the
The following institutions and people participated in the heads and staff of the Experimental Production Centre
collection and analysis of information that is included in in Ashgabat and of the provincial and district sanitary
this report: epidemiological services of the Ministry of Health and
Dr Leili Shamuradova, Vice Minister, Ministry of Health Medical Industry of Turkmenistan, as well as the WHO
and Medical Industry external evaluation experts Dr Anatoly Kondrashin and
Dr Allan Schapira.
Dr Maral Aksakova, Ministry of Health and Medical
Industry The following experts, recruited by the WHO Regional
Office for Europe contributed to Turkmenistan’s success
Dr Sofia Alieava, Ministry of Health and Medical in eliminating malaria and to the body of evidence
Industry contained in this case-study: Dr Andrei Zvantsov,
Professor Vladimir Davidyants, Professor Rossitza
The manuscript was written by Dr Rossitza Kurdova- Kurdova-Mintcheva, Professor Alla Baranova, and Dr Ara
Mintcheva, Dr Aafje Rietveld and Dr Richard Cibulskis Kysheshan.
of the WHO Global Malaria Programme. The map was
drawn by Mr Ryan Williams. Dr Robert Newman and Mrs Cara Smith Gueye reviewed
the case-study and provided important assistance and
During the preparation of the manuscript a valuable feedback. The authors remain responsible for any errors
support was obtained from Dr Mikhail Ejov, WHO and omissions.
Regional Office for Europe and Dr Bahtygul Karriyeva,
Head of the WHO country office in Turkmenistan.

Eliminating Malaria | Achieving elimination in Turkmenistan | Acknowledgements vii

Acronyms and abbreviations

ABER annual blood examination rate

ACD active case detection
ACT artemisinin-based combination therapy
API annual parasite index
CFR case–fatality rate
CISID Centralized Information System for Infectious Diseases
DDT dichlorodiphenyltrichloroethane
EQA External Quality Assurance
EPC Experimental Production Centre
GDP gross domestic product
GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria
GMEP Global Malaria Eradication Programme
G6PD glucose-6-phosphate dehydrogenase
IRS indoor residual spraying
MDA mass drug administration
MDG Millennium Development Goals
MOHMI Ministry of Health and Medical Industry
NMCP national malaria control programme
NRL national reference laboratory
PCD passive case detection
PPP purchasing power parity
QA quality assurance
RDTs rapid diagnostic tests
SES Sanitary Epidemiological Service
SOP standard operating procedure
SPR slide positivity rate
SSR Soviet Socialist Republic
USAID United States Agency for International Development
USSR Union of Soviet Socialist Republics
WHO World Health Organization

viii Eliminating Malaria | Achieving elimination in Turkmenistan | Acronyms and abbreviations

Glossary

The terms listed in this glossary are defined according to their use in this publication. They may have different
meanings in other contexts.

active case detection

 The detection by health workers of malaria infections at community and household level in population groups
that are considered to be at high risk. Active case detection can be conducted as fever screening followed by
parasitological examination of all febrile patients or as parasitological examination of the target population
without prior fever screening.

annual blood examination rate

 The number of examinations of blood slides for malaria by microscopy per 100 population per year.

case-based surveillance
 Every case is reported and investigated immediately (and also included in the weekly reporting system).

case definition (elimination programmes)

autochthonous – A case locally acquired by mosquito-borne transmission, i.e. an indigenous or introduced case
(also called “locally transmitted”).

imported – A case the origin of which can be traced to a known malarious area outside the country in which it
was diagnosed.

indigenous – Any case contracted locally (i.e. within national boundaries), without strong evidence of a direct
link to an imported case. Indigenous cases include delayed first attacks of Plasmodium vivax malaria due to locally
acquired parasites with a long incubation period.

induced – A case the origin of which can be traced to a blood transfusion or other form of parenteral
inoculation but not to normal transmission by a mosquito.

introduced – A case contracted locally, with strong epidemiological evidence linking it directly to a known
imported case (first generation from an imported case, i.e. the mosquito was infected from a case classified as
imported).

locally transmitted – A case locally acquired by mosquito-borne transmission, i.e. an indigenous or introduced
case (also called “autochthonous”).

malaria – Any case in which, regardless of the presence or absence of clinical symptoms, malaria parasites have
been confirmed by quality-controlled laboratory diagnosis.

Eliminating Malaria | Achieving elimination in Turkmenistan | Glossary ix

case investigation
 Collection of information to allow classification of a malaria case by origin of infection, i.e. imported,
introduced, indigenous or induced. Case investigation includes administration of a standardized questionnaire to
a person in whom a malaria infection is diagnosed.

case management
 Diagnosis, treatment, clinical care and follow-up of malaria cases.

case notification
 Compulsory reporting of detected cases of malaria by all medical units and medical practitioners, to either the
health department or the malaria elimination service (as laid down by law or regulation).

certification of malaria-free status

 Certification granted by WHO after it has been proved beyond reasonable doubt that the chain of local human
malaria transmission by Anopheles mosquitoes has been fully interrupted in an entire country for at least
3 consecutive years.

elimination
 Reduction to zero of the incidence of infection by human malaria parasites in a defined geographical area as
a result of deliberate efforts. Continued measures to prevent re-establishment of transmission are required.

endemic
 Applied to malaria when there is an ongoing, measurable incidence of cases and mosquito-borne transmission in
an area over a succession of years.

epidemic
 Occurrence of cases in excess of the number expected in a given place and time.

eradication
 Permanent reduction to zero of the worldwide incidence of infection caused by human malaria parasites as a
result of deliberate efforts. Intervention measures are no longer needed once eradication has been achieved.

evaluation
 Attempts to determine as systematically and objectively as possible the relevance, effectiveness and impact of
activities in relation to their objectives.

focus
 A defined, circumscribed locality situated in a currently or former malarious area containing the continuous
or intermittent epidemiological factors necessary for malaria transmission. Foci can be classified as endemic,
residual active, residual non-active, cleared up, new potential, new active or pseudo.

gametocyte
 The sexual reproductive stage of the malaria parasite present in the host’s red blood cells.

x Eliminating Malaria | Achieving elimination in Turkmenistan | Glossary

hypnozoite
 The dormant stage of the malaria parasite present in the host’s liver cells (limited to infections with P. vivax and
P. ovale).

incubation period
 The time between infection (by inoculation or otherwise) and the first appearance of clinical signs.

intervention (public health)

 Activity undertaken to prevent or reduce the occurrence of a health condition in a population. Examples of
interventions for malaria control include the distribution of insecticide-treated mosquito nets, indoor residual
spraying with insecticides, and the provision of effective antimalarial therapy for prevention or curative
treatment of clinical malaria.

local mosquito-borne malaria transmission

 Occurrence of human malaria cases acquired in a given area through the bite of infected Anopheles mosquitoes.

malaria-free
 An area in which there is no continuing local mosquito-borne malaria transmission and the risk for acquiring
malaria is limited to introduced cases only.

malaria incidence
 The number of newly diagnosed malaria cases during a specified time in a specified population.

malaria prevalence
 The number of malaria cases at any given time in a specified population, measured as positive laboratory test
results.

monitoring (of programmes)

 Periodic review of the implementation of an activity, seeking to ensure that inputs, deliveries, work schedules,
targeted outputs and other required actions are proceeding according to plan.

national focus register

 Centralized database of all malaria foci in a country.

national malaria case register

 Centralized database of all malaria cases registered in a country, irrespective of where and how they were
diagnosed and treated.

outpatient register
 List of patients seen in consultation in a health facility. The register may include the date of consultation,
patient’s age, place of residence and presenting health complaint, tests performed and diagnosis.

Eliminating Malaria | Achieving elimination in Turkmenistan | Glossary xi

parasite prevalence
 Proportion of the population in whom Plasmodium infection is detected at a particular time by means of a
diagnostic test (usually microscopy or a rapid diagnostic test).

passive case detection

 Detection of malaria cases among patients who, on their own initiative, go to a health post for treatment, usually
for febrile disease.

population at risk
 Population living in a geographical area in which locally acquired malaria cases occurred in the current year
and/or previous years.

rapid diagnostic test

 An antigen-based stick, cassette or card test for malaria in which a coloured line indicates that plasmodial
antigens have been detected.

rapid diagnostic test positivity rate

 Proportion of positive results among all the rapid diagnostic tests performed.

receptivity
 Relative abundance of anopheline vectors and existence of other ecological and climatic factors favouring
malaria transmission.

re-establishment of transmission
 Renewed presence of a constant measurable incidence of cases and mosquito-borne transmission in an area over
a succession of years. An indication of the possible re-establishment of transmission would be the occurrence
of three or more introduced and/or indigenous malaria infections in the same geographical focus, for two
consecutive years for P. falciparum and for three consecutive years for P. vivax.

relapse (clinical)
 Renewed manifestation of an infection after temporary latency, arising from activation of hypnozoites (and
therefore limited to infections with P. vivax and P. ovale).

sensitivity (of a test)

 Proportion of people with malaria infection (true positives) who have a positive test result.

slide positivity rate

 Proportion of microscopy slides found to be positive among the slides examined.

specificity (of a test)

 Proportion of people without malaria infection (true negatives) who have a negative test result.

xii Eliminating Malaria | Achieving elimination in Turkmenistan | Glossary

surveillance (control programmes)
 Ongoing, systematic collection, analysis and interpretation of disease-specific data for use in planning,
implementing and evaluating public health practice.

surveillance (elimination programmes)

 That part of the programme designed for the identification, investigation and elimination of continuing
transmission, the prevention and cure of infections, and the final substantiation of claimed elimination.

transmission intensity
 Rate at which people in a given area are inoculated with malaria parasites by mosquitoes. This is often expressed
as the “annual entomological inoculation rate”, which is the number of inoculations with malaria parasites
received by one person in one year.

transmission season
 Period of the year during which mosquito-borne transmission of malaria infection usually takes place.

vector control
 Measures of any kind against malaria-transmitting mosquitoes intended to limit their ability to transmit the
disease.

vector efficiency
 Ability of a mosquito species, in comparison with another species in a similar climatic environment, to transmit
malaria in nature.

vectorial capacity
 Number of new infections that the population of a given vector would induce per case per day at a given place
and time, assuming conditions of non-immunity. Factors affecting vectorial capacity include: the density of
female anophelines relative to humans; their longevity, frequency of feeding and propensity to bite humans; and
the length of the extrinsic cycle of the parasite.

vigilance
 A function of the public health service during a programme for prevention of reintroduction of transmission,
consisting of watchfulness for any occurrence of malaria in an area in which it had not existed, or from which it
had been eliminated, and application of the necessary measures against it.

vulnerability
 Either proximity to a malarious area or the frequency of influx of infected individuals or groups and/or infective
anophelines.

Eliminating Malaria | Achieving elimination in Turkmenistan | Glossary xiii

SUMMARY

This case-study describes and evaluates settlements. Programmatic factors – delayed diagnosis,
the policies and strategies used to contain treatment and reporting of malaria cases, especially
malaria outbreaks in Turkmenistan in in rural areas – also played a role in the occurrence of
the 1990s and early 2000s and the process the outbreaks. In addition, there was a lack of drugs
subsequently used to eliminate malaria (chloroquine and primaquine) to treat the first cases in
from the country. Lessons for countries 1998 and an insufficient supply of insecticides for vector
that are embarking upon elimination are control interventions at the beginning of the outbreak.
Since the first cases among military personnel and oil and
distilled.
gas workers were not promptly identified and properly
treated, and vector density was not rapidly reduced, it
History of malaria may be inferred that local transmission occurred not
and malaria control only in the military camp but also in the local rural
Plasmodium vivax transmission was interrupted in population. In addition, soldiers with asymptomatic
Turkmenistan by 1960 during the Global Malaria infections who were demobilized carried malaria into
Eradication Programme. The country subsequently other provinces.
maintained surveillance systems to prevent and detect During the 2002–2003 outbreak, a delay in recognizing
the reintroduction of malaria. During the period the index case was reflected in the delayed response.
1960–1980, sporadic imported and introduced malaria However, by mobilizing specialized and general
cases of P. vivax were reported, without further health services and implementing a massive scale-up
epidemiological consequences. From the 1980s of control and surveillance activities in the affected
onwards, the receptivity (the likelihood that imported areas, the national malaria programme managed to
parasites will be locally transmitted) of some areas limit the transmission to Mary province alone. After
in the country increased as a consequence of the an improvement of the malaria situation in 2004,
construction and exploitation of major water resource and in line with the malaria elimination strategy of
projects. Vulnerability (parasite importation pressure) the WHO Regional Office for Europe (EURO), the
also increased with growing population movements Government of Turkmenistan decided to reorient the
from Afghanistan and other neighbouring countries. malaria programme towards eliminating the last foci and
As a result, more malaria cases were imported in the preventing reintroduction. As a result of the elimination
1980s and 1990s and were followed by an increase in efforts, the last autochthonous cases in Turkmenistan
autochthonous cases. The health system did not respond were registered in 2004. In 2010, WHO certified the
to the increased vulnerability and receptivity. country as free of malaria.
In 1998–1999 and in 2002–2003, two outbreaks of P. vivax
malaria occurred in Mary province near Turkmenistan’s
Control of the outbreaks
border with Afghanistan. The outbreaks first affected Interventions for the containment of the outbreaks were
military staff and oil and gas workers deployed near coordinated by the Sanitary Epidemiological Service
the border and subsequently the population of nearby (SES). Mobile teams consisting of epidemiologists,

Eliminating Malaria | Achieving elimination in Turkmenistan | Summary xv

parasitologists, entomologists, clinicians and laboratory and guidelines. Once transmission was interrupted,
technicians were assigned to the affected areas. greater attention was paid to identifying imported
An integrated approach was applied that included: cases – setting up an outpatient consulting room
in Ashgabat on tropical diseases for travellers;
• eliminating the sources of infection by, clinical examination of travellers from Afghanistan
ŠŠ timely case detection through active and passive with malaria examination of febrile individuals at
case detection followed by radical treatment, the border sanitary quarantine points; sustained
vigilance in the general health services.
ŠŠ prompt and comprehensive investigation of
every case to detect and treat further infections, • The national territory and neighbouring areas were
and define the population at risk of malaria stratified by levels of receptivity according to the
transmission, and results of entomological monitoring. Entomological
interseasonal prophylactic treatment with investigations were undertaken and integrated
ŠŠ
primaquine for all who had been exposed to the vector control activities were applied in transmission
transmission risk; foci. Larval control using fish was widely applied.
No IRS has been performed since 2005 but a stock
• conducting integrated vector control guided by of insecticides is maintained by SES in case of
investigations of foci, using a combination of indoor emergency.
residual spraying (IRS), larviciding, environmental
management and housing improvements; and • Community awareness was increased through the
mass media and other avenues, and the participation
• providing health education and prevention for of the whole population in malaria elimination and
populations in the foci through seasonal chloroquine prevention was encouraged.
prophylaxis.
The malaria control programme benefited from an
upgrading of health facilities, including recruitment
Elimination of malaria, 2004–2010 and training of staff and provision of equipment and
A comprehensive approach was adopted in order to transport (microscopes, computers, cars). The national
eliminate the source of infection, reduce transmission by system of external quality assurance (EQA) of malaria
vectors and provide health education and prevention to was improved and covered all laboratories where malaria
the populations affected. A malaria focus was considered was diagnosed. The national reference laboratory,
the minimum unit for antimalarial action. A focus which conducted the national EQA, was included in
register was established and regularly updated to reflect an international EQA programme and internationally
the functional status of each focus (e.g. transition from a certified.
new active focus to a focus that had been cleared, or vice
versa). Various strategies were employed to interrupt Strong political commitment to malaria elimination
transmission: and broad governmental support played an important
role in malaria elimination in Turkmenistan. The
• Both passive and active case detection were Government and WHO EURO provided the funding for
conducted. There was case-based surveillance, the interventions, which were regulated in the National
which involved the timely recording, reporting and Strategy and Plan of Action for Malaria Elimination.
investigation of laboratory-confirmed malaria cases Assistance from WHO in developing strategies,
as well as maintaining a database of individual cases policies, strategic plans and guidelines ensured that the
at district, provincial and national levels. Prompt complex of measures was based on up-to-date WHO
treatment of patients was provided free of charge, recommendations and was properly conducted with
in accordance with the updated national policies adequate coverage. WHO also played an essential

xvi Eliminating Malaria | Achieving elimination in Turkmenistan | Summary

role in strategic guidance and technical assistance
on capacity building, disease management, vector
control, malaria surveillance, operational research,
community involvement and intersectoral collaboration.
The Turkmen SES, with its comprehensive network
of field presence in every district, coordinated the
malaria programme activities. Its expertise in malaria
control and elimination was highly instrumental in the
achievement of the goals.

Outlook for the future

A plan of action for prevention of malaria reintroduction
in the country has been developed and introduced,
aiming at prompt and timely response to changes in
the receptivity and vulnerability of the territory of the
country, maintaining a high vigilance, timely detection
of any malaria case and preparedness for undertaking
response actions when required.

The lessons learned during the malaria outbreaks and

subsequent elimination efforts highlight the importance
of maintaining epidemiological surveillance at a level
that will ensure prompt detection and treatment of
cases, as well as timely response to any emergency.
Financial allocations to fund malaria activities should
continue: Turkmenistan has an ongoing duty – not only
to its own people but also to its neighbours – to sustain
this dedication to remaining free of malaria.

Eliminating Malaria | Achieving elimination in Turkmenistan | Summary xvii

Достижение элиминации малярии в
Туркменистане
Тематическое исследование

Резюме из Афганистана и других пограничных

В данном тематическом исследовании стран. В результате в 1980-х и 1990-х годах
дается описание и оценка мер политики и увеличилось число случаев завозной
стратегий, применявшихся в Туркменистане малярии, а вслед за этим и число автохтонных
для подавления вспышек малярии в 1990-х случаев вследствие местной передачи.
и в начале 2000 х годов, а также процесса, Система здравоохранения не отреагировала
применяемого в дальнейшем для элиминации на повышение уровней уязвимости и
малярии в этой стране. Особо выделены восприимчивости.
уроки, полезные для стран, которые
также приступили к элиминации данного В 1998–1999 и 2002–2003 годах в Марыйском
заболевания. районе вблизи границы Туркменистана с
Афганистаном произошли две вспышки
История малярии и борьбы с ней малярии, вызванной P. vivax. Вспышки
Передача возбудителя малярии Plasmodium вначале затронули военнослужащих и
vivax была прервана в Туркменистане к рабочих-нефтяников, дислоцированных
1960 году в ходе реализации Глобальной вблизи границы, а затем – жителей соседних
программы по ликвидации малярии. В населенных пунктов. Поздний диагноз
дальнейшем в стране поддерживалась система и задержки с лечением и сообщением о
эпидемиологического надзора с целью выявленных случаях, особенно в сельской
профилактики завоза и восстановления местности, также явились факторами, которые
передачи малярии. В период, охватывающий сыграли важную роль в возникновении
1960–1980-е годы, отмечались спорадические вспышек. Кроме того, для лечения
случаи завозной и вторичной от завозной первых случаев в 1998 году отсутствовали
вследствие местной передачи малярии, необходимые лекарства (хлорохин и
вызванной P. vivax, не имевшие, однако, примахин) и не хватало инсектицидов
эпидемиологических последствий. Начиная с для борьбы с переносчиками малярии в
1980-х годов восприимчивость (способность начале вспышки. Поскольку первые случаи
местных переносчиков поддерживать заболевания среди военнослужащих и
передачу малярии от завезенных паразитов) рабочих-нефтяников не были своевременно
некоторых регионов страны выросла в выявлены и больные не получили
результате строительства и эксплуатации надлежащего лечения, а передача малярии не
крупных водохозяйственных объектов. была быстро снижена, можно предположить,
Уязвимость территории (мера вероятности что местная передача происходила не только
завоза инфекции) также увеличилась в в пределах военного городка, но и среди
связи с ростом перемещения населения местного сельского населения. В дополнение

Eliminating Malaria | Achieving elimination in Turkmenistan | Достижение элиминации малярии в Туркменистане xix
к этому демобилизованные военнослужащие с заболевания посредством применения
бессимптомной инфекцией занесли малярию в активных и пассивных методов
другие области республики. выявления больных с последующим
радикальным лечением,
В ходе вспышки 2002–2003 годов позднее своевременного и всестороннего
ŠŠ
выявление первичного случая привело к эпидемиологического расследования
запоздалому реагированию. Однако благодаря каждого случая малярии в целях
мобилизации специализированных и общих выявления других случаев и их лечения,
служб здравоохранения и принятию в а также определения групп населения,
массовом масштабе экстренных мер по борьбе подверженных риску заражения
с вспышечной заболеваемостью и усилению малярией,
эпидемиологического надзора на пораженных
территориях в рамках государственной ŠŠ межсезонной химиопрофилактики
программы по борьбе с малярией удалось примахином всех, кто подвергался
ограничить перенос только Марыйской риску заражения болезнью;
областью. После улучшения ситуации • Применение комплексных мер борьбы с
по малярии в 2004 году и в соответствии переносчиками инфекции, где основное
со стратегией элиминации малярии место отводилось обработке помещений
Европейского регионального бюро ВОЗ инсектицидами остаточного действия
(EURO) правительство Туркменистана приняло (ОПИОД). Наряду с ОПИОД также
решение о переориентации программы по применялись ларвициды и меры по
борьбе с малярией на элиминацию последних оздоровлению экологической обстановки и
очагов и профилактику завоза и повторного улучшению жилищных условий;
восстановления передачи малярии. В • Обеспечение санитарного просвещения и
результате элиминационных мер последние предупреждения заболеваемости населения
автохтонные случаи в Туркменистане были в очагах малярии за счет сезонной
зарегистрированы в 2004 году. В 2010 году химиопрофилактики хлорохином.
ВОЗ сертифицировала территорию этой
страны как свободную от малярии. Элиминация малярии,
2004–2010 годы
Борьба с вспышками малярии
Для борьбы с малярией был принят
Меры по сдерживанию распространения комплексный подход, предусматривавший
вспышек заболевания координировались элиминацию источников заражения, снижение
санитарно-эпидемиологической службой уровня передачи инфекции и улучшение
(СЭС). Для работы на пораженных санитарного просвещения и профилактики
территориях были сформированы выездные среди населения. За минимальную единицу,
бригады в составе эпидемиологов, требующую применения противомалярийных
паразитологов, энтомологов, врачей- мер, был принят малярийный очаг. Был
клиницистов и лаборантов. Применялся создан и регулярно обновлялся регистр
комплексный подход, предусматривавший: очагов, отражающий функциональный статус
каждого очага (т. е. переход от статуса “новый
• Элиминацию источников инфекции путем активный очаг” к статусу “оздоровленный”
ŠŠ своевременного выявления случаев или наоборот). Для прерывания передачи

xx Eliminating Malaria | Achieving elimination in Turkmenistan | Достижение элиминации малярии в Туркменистане

использовались различные стратегии, в том • Через СМИ и другие каналы повышался
числе: уровень информированности населения,
поощрялось участие всего населения в
• Проводилось как пассивное, так и мерах по элиминации и профилактике
активное выявление случаев заболевания. малярии.
Осуществлялся эпиднадзор на основе
случаев заболеваний, включавший Реализации программы по борьбе с
своевременную регистрацию, малярией способствовала модернизация
извещение и исследование лабораторно учреждений здравоохранения,
подтвержденных случаев заболевания предусматривавшая обучение персонала,
малярией, а также ведение базы данных а также обеспечение таких учреждений
по отдельным случаям на уровне необходимым оборудованием и транспортом
районов, областей и страны в целом. (микроскопами, компьютерами,
Пациентам бесплатно предоставлялось автомобилями). Национальная система
ранее лечение в соответствии с новыми внешнего контроля качества (ВКК)
общенациональными правилами и лабораторных исследований малярии
руководствами. После того как было была усовершенствована и распространена
осуществлено прерывание передачи, на все лаборатории, где проводилась
внимание переносилось на выявление диагностика малярии. Национальная
случаев завоза малярии: так, в Ашхабаде референтная лаборатория, осуществляющая
был открыт консультативный кабинет общенациональный ВКК, была включена в
по тропическим заболеваниям для лиц, международную программу ВКК и получила
выезжающих и прибывающих из-за международную сертификацию.
рубежа; проводился медицинский осмотр
лиц, прибывающих из Афганистана, и Важную роль в элиминации малярии в
проверка на малярию лиц с симптомами Туркменистане сыграли твердая политическая
лихорадки в пограничных санитарных приверженность решению этой задачи
пунктах; поддерживалась постоянная и широкая государственная поддержка.
бдительность всех служб здравоохранения. Правительство страны и Европейское бюро
• Территория страны и соседние ВОЗ предоставили финансовые средства
области были зонированы по уровням для проведения мер по борьбе с малярией,
восприимчивости в соответствии с осуществление которых регулировалось
результатами энтомологического Национальной стратегией и планом действий
мониторинга. Были проведены по элиминации малярии. Благодаря
энтомологические исследования и помощи ВОЗ в разработке стратегии,
введены комплексные методы борьбы политики, стратегических планов и
с переносчиками малярии в очагах руководящих принципов в основу комплекса
передачи. Широко применялись принимаемых мер были положены последние
мероприятия, направленные на рекомендации ВОЗ, и соответствующие
борьбу с личинками переносчиков с мероприятия проводились надлежащим
использованием рыб-ларвифагов. ОПИОД образом, обеспечивая достаточный охват
не проводились с 2005 года, однако на населения. ВОЗ также сыграла важную
случай чрезвычайных ситуаций СЭС роль в обеспечении стратегического
держит запас инсектицидов. руководства и технической помощи в

Eliminating Malaria | Achieving elimination in Turkmenistan | Достижение элиминации малярии в Туркменистане xxi
таких областях, как укрепление кадрового в уровне восприимчивости и уязвимости
потенциала, улучшение диагностики и территории страны к малярии, сохранение
лечения, борьба с переносчиками инфекции, повышенной бдительности, своевременное
эпидемиологический надзор за малярией, выявление случаев малярии и обеспечение
проведение оперативных исследований, готовности по принятию чрезвычайных мер
вовлечение местных сообществ в при необходимости.
межотраслевое сотрудничество. Координацию
мероприятий в рамках программы по борьбе с Опыт, полученный в ходе борьбы со
малярией осуществляла СЭС Туркменистана, вспышками малярии и в процессе элиминации
располагающая широкой сетью отделений малярии, указывает на важность поддержания
на местах в каждом районе. Знания и опыт эпидемиологического надзора на уровне,
сотрудников СЭС в области борьбы с малярией который обеспечивает незамедлительное
и ее элиминации в значительной степени выявление случаев инфекции и лечение
способствовали достижению поставленных больных, а также своевременное реагирование
целей. на любые чрезвычайные ситуации.
Необходимо продолжить выделение средств
Перспективы на будущее на противомалярийные мероприятия: долг
Для предотвращения повторного Туркменистана – не только перед своим
восстановления передачи малярии в населением, но и перед соседними странами
Туркменистане был разработан и принят план – состоит в продолжении этих усилий,
действий, направленный на незамедлительное позволяющих ему оставаться свободным oт
и своевременное реагирование на изменения малярии.

xxii Eliminating Malaria | Achieving elimination in Turkmenistan | Достижение элиминации малярии в Туркменистане
INTRODUCTION

The malaria elimination case-study elimination efforts over the past two decades and the WHO
series certification process for Turkmenistan in 2009–2010. They
If countries are to make well-informed are familiar with the country and its health system, and with
the wealth of malaria-related information collected and
decisions on whether or how to pursue
analysed as part of the certification requirements.
malaria elimination, an understanding
of historical and current experiences Data collection and analysis methods for the case-study
of malaria elimination and prevention are elaborated in Annex 1.
of reintroduction in other countries
– particularly those in similar eco-
Malaria in the WHO European
epidemiological settings – is critical.
Region
The Global Malaria Programme of the
World Health Organization (WHO/ After the remarkable success of the WHO Global
Malaria Eradication Programme that was launched in
GMP) and the Global Health Group of
1955, including the achievement of malaria-free status
the University of California, San Francisco
in almost all countries of the WHO European Region,
– in collaboration with national malaria
the malaria situation deteriorated in the 1990s (1–6).
programmes and other partners and There was a massive return of malaria into areas of
stakeholders – are jointly conducting a Central Asia and the Transcaucasian countries of the
series of case-studies on elimination of WHO European Region, and the disease assumed
malaria and prevention of reintroduction. epidemic proportions in Tajikistan and in Turkey. This
The objective of this work is to build an deterioration was the result of changes in political and
evidence base to support intensification of economic conditions, the post-Soviet economic collapse,
malaria elimination as an important step in military conflicts, mass population migration, extensive
achieving international malaria targets. development projects, degradation of the public health
system, and the near or complete discontinuation of
Ten case-studies are being prepared that, together, will malaria prevention and control activities (1–3, 5).
provide insights into and lessons to be learnt from a wide
range of elimination approaches, geographical settings and The malaria-affected Member States of the WHO
progress towards the goal of zero local transmission. European Region joined the Roll Back Malaria
initiative launched by the United Nations Children’s
Turkmenistan was selected for a malaria elimination case- Fund (UNICEF), the United Nations Development
study because of its recent elimination success – exemplified Programme (UNDP), WHO and the World Bank
by the achievement of official certification, by WHO in in 1998; with rapid scale-up and sustained efforts,
2010, of freedom from malaria – and because details of the they achieved a marked reduction in the levels of
country’s successful fight against malaria have not yet been transmission and of malaria morbidity (7, 8). In 2005,
made available in the public domain. The main authors of these countries all endorsed the Tashkent Declaration,
the study have been closely involved in the national malaria The Move from Malaria Control to Elimination (9).

Eliminating Malaria | Achieving elimination in Turkmenistan | Introduction 1

A new regional elimination strategy was put in place, Malaria in Turkmenistan
with the ultimate goal of interruption of P. falciparum
malaria transmission in Central Asia by 2010 and the Turkmenistan is one of the Central Asian countries
elimination of local transmission of malaria in the entire where malaria was eliminated in the 1960s only to
WHO European Region by 2015 (10). return in the 1990s in the wake of the break-up of the
former Union of Soviet Socialist Republics (USSR)
In 2007, the WHO European Region held a meeting in and subsequent geopolitical and economic events in
Ashgabat, Turkmenistan, to assess the progress achieved the region (5, 6, 14, 15); it declared its independence in
towards malaria elimination (11). Steady progress was 1991. Enormous efforts and substantial funding were
reported for the entire Region, including a 14-fold reduction needed to set up and implement malaria control and
in the reported overall number of malaria cases – from elimination programmes, scale up antimalaria activities,
37 173 to 2679 – during the period 1999–2006, and a combat outbreaks in 1998–1999 and 2002–2003, and
reduction in P. falciparum transmission, with the annual finally achieve the goal of malaria elimination (Figure 1).
number of the local cases in Tajikistan falling from a peak Turkmenistan was certified malaria-free by WHO in
of 831 in 2000 to 28 in 2006 (11, 12). It was concluded that 2010 – the first country to achieve this goal in the WHO
all countries affected by autochthonous malaria would be European Region since the 1970s (16, 17).
able to proceed with malaria elimination as planned and
that, by 2010, Armenia and Turkmenistan would be able to This case-study presents an analysis and evaluation
achieve elimination of P. vivax transmission, and Tajikistan of the malaria situation in Turkmenistan, the
elimination of P. falciparum transmission. containment of outbreaks and the processes required
to achieve malaria elimination in the country. It
The scaling up of malaria control efforts in the WHO covers reasons for the deterioration of the malaria
European Region has indeed resulted in progress towards situation, the main interventions used to cope with the
malaria elimination as planned, made possible by long- ensuing epidemics, best practices of epidemiological
term and predictable funding and by wide coverage with surveillance and control, and lessons learnt. The study
interventions, including close cross-border collaboration describes an example of contemporary, evidence-based
and strengthened surveillance and monitoring. Only 58 elimination strategies and policies, applied in a case of
indigenous malaria cases were reported in 2011, down from reintroduction of malaria transmission followed by a
the peak of 90 712 cases in 1995. Armenia and Turkmenistan successful effort to reach malaria elimination. It also
have achieved WHO certification of their malaria-free status, highlights the strong political commitment and the
and the last case of autochthonous P. falciparum malaria in mobilization of human resources that were needed to
the Region was reported in 2008 (12, 13). reach the elimination goal.

Figure 1. Reported malaria cases in Turkmenistan, 1991–2010

140

120
Number of reported malaria cases

100

80

60

40

20

0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Years
autochthonous imported

Source: CISID (Centralized Information System for Infectious Diseases), Ministry of Health and Medical Industry

2 Eliminating Malaria | Achieving elimination in Turkmenistan | Introduction

COUNTRY BACKGROUND

Geography, population and Demographic data for Turkmenistan are presented

economy in Annex 2. The country is multi-ethnic, with more
Turkmenistan is situated in Central Asia, to the east of than 100 ethnic groups (Turkmens 77%; Uzbeks 9.2%;
the Caspian Sea. Its capital is Ashgabat. Some 80% of its Russians 6.7%; others 7.1%). In 2009, the population
area of 488 100 km2 is covered by the Karakum Desert was 5.1 million, 49% of whom were living in urban
(18). Turkmenistan shares borders with Afghanistan, the areas (20). The country is very unevenly populated: most
Islamic Republic of Iran, Kazakhstan and Uzbekistan, people live in cities, in oases and around water bodies.
of which only Afghanistan still has a significant malaria Average population density in desert and mountainous
problem in the border areas. The Kopet Dag mountain areas is 1 person/km2; in areas of artificial irrigation this
range along the south-western border with the Islamic figure rises to more than 100 people/km2. The most
Republic of Iran reaches an altitude of 2912 metres. densely populated area – and the area where the last
The only other areas of significant elevation are the malaria cases occurred in 2004 (18) – is the estuary of the
Great Balkan Range in the west of the country (Balkan Murgab River, with more than 240 inhabitants per km2.
Province) and the Koytendag Range on the south-
eastern border with Uzbekistan (Lebap Province) The administration division, political organisation and
(Figure 2). economy are presented in Annex 3.

The climate is hot and arid. From May to September Turkmenistan is increasingly exploiting its natural
daytime air temperatures exceed 40°C, peaking in July. gas reserves, which are the fourth largest of any
As a result, the environmental conditions for malaria country in the world. It also has large reserves of oil,
transmission exist mainly in oases and around water iodine, bromine, sulfur, etc. Gas and oil industries
bodies, and agricultural development is based entirely on are leading branches of the economy: the energy
artificial irrigation (18, 19). A great part of the irrigated potential is estimated at 45 billion tons of oil equivalent,
land is planted with cotton and rice; the country is corresponding to one-fifth of the world’s deposits of gas
among the world’s 10 major cotton producers. To satisfy and oil. The most developed sectors of industry include
the water supply needs for industries, and primarily for fuel and energy, chemistry and construction (18, 19).
agriculture and farming, Turkmenistan uses the waters
of the Amu Darya – the largest Central Asian river – and According to World Bank data, the gross domestic
other Turkmen rivers, as well as a system of artificial product (GDP) of Turkmenistan in 2009 was
canals. The canals include the 1375-km Karakum Canal, US$ 19 947 368 421, corresponding to a GDP per capita
which skirts the Karakum Desert, carrying water of US$ 3903. The country is classified as a “lower middle
westwards from the Amu Darya and has a system of income country” (21). Adjusted for purchasing power
water reservoirs, and the Turkmen Canal which supplies parity (PPP), the gross national income per capita is
water to the northern regions of the country. There are US$ 7490 (22). The following services and commodities
also large subterranean water reserves and the Altyn are provided free of charge by the Government to the
Asyr Lake is being constructed in the centre of the population: gas, electricity, water, table salt, education
Karakum Desert. and a wide range of health services. Charges for
telephone services and public transport are nominal.

Eliminating Malaria | Achieving elimination in Turkmenistan | Country Background 3

Health system and population illnesses and injuries; curative and preventive measures
health profile against parasitic and other diseases; immunization;
community awareness raising and health education;
The health system in Turkmenistan has three and mother-and-child health protection measures. The
components (23): health houses play an essential role in the detection and
• The Ministry of Health and Medical Industry follow-up of malaria patients.
(MOHMI), with its: The public health care delivery system is structured in
•  rimary health care institutions,
P accordance with the administrative and geographical
pharmaceutical services and other institutions division of the country at primary etrap (district),
such as hospitals, outpatient clinics, pharmacies intermediate velayat (province), Ashgabat city and
and research centres established under other central (republican) levels. At each administrative level
ministries, agencies and Government bodies there is a network of hospitals, health centres, infectious
and organizations. disease isolation units, laboratories, etc., as well as
• Some nongovernmental organizations, such as the sanitary epidemiological services, which are responsible
Trade Union of the Medical Profession, National for communicable disease control including antimalaria
Red Crescent Society and others that provide health interventions.
services. Per capita government expenditure on health exceeded
US$ 100 in 2005. A broad range of services is provided
Primary health care services in urban and rural areas free of charge to patients, including all services related to
are provided by municipal “health houses”, which offer: communicable and vector-borne diseases such as malaria.
diagnostic procedures; treatment of the most common
Figure 2. Map of Turkmenistan

TURKMENISTAN
Kazakhstan

Kazakhstan

Uzbekistan
DASHOGUZ

BALKAN

AHAL LEBAP

MARY

Legend
Malaria outbreak Iran (Islamic Republic of) Afghanistan
Secondary indigenous cases

Malaria spread resulting in local transmission

Gushgy
Malaria spread, no local transmission 0 40 80 160 Kilometers

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever Data Source: World Health Organization
on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, Map Production: Global Malaria Programme (GMP)
or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines World Health Organization
for which there may not yet be full agreement. © WHO 2012 All rights reserved.

4 Eliminating Malaria | Achieving elimination in Turkmenistan | Country Background

Health care policies are presented in Annex 4 and • life expectancy at birth: 63 years (60 for men and
the main health indicators in Annex 5. Overviews of 67 for women);
health care service facilities and basic hospital resource • under-five mortality rate: 45 deaths per 1000 live
indicators are presented in Tables 1 and 2 below. births;
Turkmenistan ranked 102nd on the UNDP Human • maternal mortality rate: 77 per 100 000;
Development Index country listing in 2011, at a medium • leading causes of death: cardiovascular
level of human development (24). WHO provides the disease (27%), neuropsychiatric disease (13%),
following population health profile for Turkmenistan for parasitic and other infectious diseases (9%),
2009 (25): respiratory infections (9%), trauma (8%).

Table 1. Health care service facilities in Turkmenistan in 2010

Health care service facilities Number
Central-level facilities 40
Provincial and Ashgabat city health facilities 214
District and city-level facilities 55
Village health houses and health centres 1 643
Municipal health houses 26
Source: Statistical department, Ministry of Health and Medical Industry

Table 2. Basic hospital resource indicators

Indicator Value
Number of hospitals per 100 000 population 2
Number of hospital beds per 100 000 population 433
Average stay in hospital (days) 10
Source: Statistical departement, Ministry of Health and Medical Industry, reference 19

Eliminating Malaria | Achieving elimination in Turkmenistan | Country Background 5

History of malaria and malaria control

Parasites and vectors River valley, water reservoirs were treated with petrol
In the past, Plasmodium vivax, P. falciparum and P. malariae against mosquito larvae, and quinine was distributed
have all been reported in Turkmenistan. Since 1960, to the population, contributing to a reduction of the
only P. vivax has been transmitted in the country. The disease in Merv city and its outskirts.
principal malaria vectors are Anopheles pulcherrimus and From 1930 onwards the problem was addressed more
An. superpictus; a third vector, An. hyrcanus, possibly broadly and systematically. A number of specialized
plays a minor role in certain circumstances (Annex 6). institutions were established to combat malaria,
including the Tropical Institute, 21 malaria control
Pre-control posts and 101 malaria units, staffed by malariologists,
Malaria has been known in Turkmenistan since ancient entomologists and other specialists. Large-scale vector
times, under the name of gyzzyrma or ystma. It ranked control was initiated, using oiling of water reservoirs,
among the principal infectious diseases of Turkmenistan widespread spraying with DDT, deployment of
and was a major burden for the rural population (18, 19). Gambusia affinis larvivorous fishes in the Murgab and
It is said that malaria was particularly prevalent in the Amu Darya river basins, in-filling of unused water
Middle Ages and that in the 14th century Timur Lenk1 reservoirs and use of mosquito nets. This was combined
combated it by killing people suffering from fever in the with mass drug administration (MDA) of the population
city of Merv (now Mary). in the active malaria foci – every individual was treated
with antimalarial medicines regardless of whether
In the late 19th and early 20th centuries, malaria was still they had a current or recent malaria infection. These
an important health problem in Turkmenistan. Archival interventions led to a substantial fall in the malaria
records show that, in the Merv district, nearly 90 000 burden.
persons had malaria in 1896 and that some 20 000 died
of the disease in 1896–1897. At that time, malaria swept In 1937, mass screening followed by treatment of
whole villages. From 1904 onwards malaria subsided, detected cases was started. Nearly 128 000 people
emerging again during the First World War (1917 – were examined by microscopy in 1938, of whom 7800
1922). At the time there were no drugs or resources for (about 6%) were positive. In the same year, 78% of the
large-scale interventions against the disease (14, 15, 18, registered patients were given anti-relapse treatment
19, 26). using primaquine. It has been reported that malaria
prevalence was reduced by 47% between 1937 and 1941
Initial control efforts (19). Many data from that period were lost in 1948 in the
massive earthquake that destroyed Ashgabat, the old
In the 1920s, limited control efforts were initiated. capital city of Turkmenistan.
Malaria posts were established in Bayram-Aly, Dashoguz,
Kerky and Charjow (now Lebap province) and in Kara- Initial elimination efforts
Kala district (now Makhtumkuly district). In 1923, major
land reclamation work was undertaken in the Murgab In the years following the Second World War, the USSR
set the goal to “eliminate malaria as a mass disease”,
1
Also known as Tamerlane: conqueror and ruler of an area including in the Turkmen Soviet Socialist Republic.
from Turkey to Mongolia (1336–1405).

Eliminating Malaria | Achieving elimination in Turkmenistan | History of malaria and malaria control 7
Malaria surveillance and control were scaled up. By the Sanitary Epidemiological Service (SES) of the
that time, the antimalaria network in Turkmenistan MOHMI; they included epidemiological surveillance
included 42 malaria control stations, 23 malaria posts directed at early detection of any malaria case, timely
staffed by feldshers1 and 332 quinine distribution posts. response (immediate radical treatment, epidemiological
A system for one-year follow-up of all malaria patients investigation of every case and new focus), malaria
was established, which included monthly blood testing screening of risk groups and vector control interventions
at dispensaries. Large-scale antimalaria interventions if needed, training of medical personnel, health
led to a dramatic reduction in the malaria burden (see education, etc.
Figure 3): the annual morbidity rate dropped from
558 per 100 000 population in 1950 to 3.4 per 100 000 Between 1961 and 1969, isolated malaria cases were
population in 1956, and elimination was achieved by registered almost every year, mainly at the border
1961. However, Turkmenistan was not certified by with Afghanistan. Few of these cases were imported.
WHO as malaria-free, because the country was at that However, there were also autochthonous cases, classified
time a part of the USSR, which still included some as “introduced” (first-generation local transmission),
endemic areas. indicating ongoing local transmission, albeit on a limited
scale and in limited areas. During this period, two
parasite carriers and 30 malaria patients were registered;
Figure 3. Malaria incidence rate per 100 000
population in Turkmenistan, 1950–1956 29 of the patients were classified as local cases, of
600 which four were the result of blood transfusion. Of the
remaining 25 patients, 22 lived close to the border with
Number of cases per 100 000 population

500
Afghanistan, where malaria prevalence was high. It was
400
assumed that these infections were introduced (Table
3). Unfortunately, detailed epidemiological information
300 on the two asymptomatic, four induced and remaining
25 autochthonous cases that were reported in the 1960s
200
is unavailable.
100
Isolated imported cases continued to be registered
0 in the 1970s (18). In the 1980s, however, malaria
1950 1951 1952 1953 1954 1955 1956
Years importation increased dramatically, mostly in the
Source: Ministry of Health and Medical Industry capital Ashgabat and in Lebap and Mary provinces;
this was attributed to the return of demobilized troops
Prevention of reintroduction, from Afghanistan (Figure 4) (12). The SES responded
1961–1990 with prompt detection, treatment and follow-up of
From 1961 to 1990, Turkmenistan had no problems patients for 2 years. The development of malaria
with malaria. To prevent the reintroduction of epidemics was prevented at the time: only five isolated
malaria transmission, a vigilance system was set up autochthonous cases were registered in 1989 and
in accordance with the recommendations of the none in 1990 (12). Most of the cases were detected in
WHO Global Malaria Eradication Programme. All the southern Mary and Lebap provinces bordering
public health care institutions were involved. The Afghanistan, known for their high level of receptivity
activities were carried out under the supervision of (foothills, oasis areas, water bodies) and vulnerability
(cross-border population migration).
1
A health care professional who provides various medical
services in the Russian Federation and other countries of the
former Soviet Union, mainly in rural areas.

8 Eliminating Malaria | Achieving elimination in Turkmenistan | History of malaria and malaria control
Table 3. Reported malaria in Turkmenistan, 1961–1969

Reported malaria cases 1961–1969

32

Parasite carriers
Patients with clinical symptoms without clinical
symptoms
30 2
Locally acquired cases Imported cases
29 1

Infections due to mosquito-borne Infections

transmission subsequent to
blood transfusion
(assumed
induced cases)
25 4

Patients living Patients living

on Afghan elsewhere in
border (assumed Turkmenistan
introduced cases) (assumed
indigenous cases)
22 3
Source: references 18, 19

Figure 4. Reported malaria cases in Turkmenistan,

P. vivax is the only malaria parasite known to have 1980–1990
been transmitted in the country since 1960. The last 40
Number of reported malaria cases

indigenous case of P. malariae was detected in 1988

in a 76-year-old woman. Indigenous P. falciparum was 30

eliminated before 1960, probably in the late 1950s. Single

20
cases of P. falciparum importation from Africa were
observed in 1980 and in 1981 in Lebap, and two more 10
in Ashgabat in 1988. In 1982, one falciparum case was
imported to Bayramaly from Afghanistan. No secondary 0
1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990
cases occurred on any of these four occasions (27). Years
autochthonous imported

Source: Centralized Information System for Infectious Diseases (CISID)

Eliminating Malaria | Achieving elimination in Turkmenistan | History of malaria and malaria control 9
Outbreaks and their control, The following year, asymptomatic carriers – mainly
1991–2003 demobilized military personnel – spread the infection
from the first active focus in Gushgy/Serhetabad to
In the 1990s, after the independence of Turkmenistan, all provinces of the country and to Ashgabat city,
the country’s malaria situation gradually worsened. The resulting in internal importation. However, intensified
reported data for this period are summarized in Figure 5. surveillance resulted in this internal importation
Altogether, 78 cases of P. vivax were registered over the being followed by local transmission only in Atamurat
period 1991–1997, 51 of them imported. Autochthonous district in Lebap province where two indigenous cases
cases, considered sporadic, were registered every were registered (Table 4, Figure 2). In the initial focus
year. Following changes in the malaria potential of in Gushgy/Serhetabad, another five local cases were
the country’s southern border areas, two outbreaks detected in 1999. Among the total 33 locally acquired
occurred, in 1998–1999 and in 2002–2003 (5, 12, 14, 15, 18, cases in 1999, three occurred in children under 14 years
19, 28). of age (1–3, 14, 15, 18, 19, 29). That same year there was
also importation of malaria infections from abroad:
Figure 5. Reported malaria cases in Turkmenistan, nine imported cases, originating from Afghanistan,
1991–2003 Azerbaijan, Tajikistan and Uzbekistan, were registered
140 in the Lebap, Ahal and Balkan provinces and in
Number of reported malaria cases

120 Ashgabat city.

100

80 To contain the malaria outbreak, the most severe

60 since 1960, and to prevent further spread of malaria
40 throughout the country, in late 1998 and 1999 MOHMI
20 mobilized the SES and general health facilities to take
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
urgent measures and strengthen the epidemiological
Years
Autochthonous Imported
surveillance and control of malaria in the area. The
Source: Ministry of Health and Medical Industry WHO Regional Office for Europe provided technical
assistance and financial support to the country (14). A
plan of action for malaria control and prevention for
1998–1999 outbreak the period 1999–2001 was developed and approved by a
decree issued by MOHMI (30). The main strategic areas
In 1998, the malaria situation in Turkmenistan took a and activities are summarized in Table 5.
dramatic turn for the worse: 137 malaria cases were
registered in the country, 115 of them locally acquired The antimalaria interventions that were initiated in
cases of vivax malaria, including 108 cases (93.9% of all late 1998 resulted in containment of the epidemic and
autochthonous cases and 78.8% of all cases reported a significant reduction in malaria morbidity within
in 1998) in Gushgy (now Serhetabad) district of Mary the foci. The number of autochthonous cases in the
province, mainly among military personnel. The Gushgy/ country fell dramatically, from 115 in 1998 to 33 in
Serhetabad outbreak occurred in a military training 1999 to 14 single autochthonous cases in 2000. Ten
camp located near the border with Afghanistan. Because imported cases were also reported in 2000. By 2001,
of the remote location and absence of local indigenous there were only five indigenous (presumed introduced)
sources of infection, the national malaria programme cases in two districts of Lebap province, in addition to
assumed initially that the malaria infections were caused three imported cases from Azerbaijan, Tajikistan and
by infected mosquitoes from Afghanistan where there Uzbekistan, detected in the cities of Ashgabat, Atamurat
were still highly endemic settlements. Moreover, the and Turkmenabat. The year 2002, however, saw the start
radical treatment of detected cases and vector control of a new outbreak in Mary province.
interventions were delayed at the start of the outbreak
because of the lack of antimalarial drugs and insecticides.

10 Eliminating Malaria | Achieving elimination in Turkmenistan | History of malaria and malaria control
Table 4. Overview of reported local malaria cases in 1999
Number of cases
Internal importation:
acquired in Mary Population characteristics
Total Indigenous province and
detected in non-
Province endemic areas
3 military personnel;
Ashgabat city 4 0 4
1 unemployed person
1 military officer; 1 construction worker;
Ahal 4 0 4
2 unemployed persons
Balkan 1 0 1 1 construction worker
3 military and demobilized military personnel;
Dashoguz 4 0 4
1 unemployed person
13 military and demobilized military personnel;
Lebap 15 2 13
2 children under 14 years
3 military personnel; 1 unemployed person;
Mary 5 5 0
1 child under 14 years
22 military and demobilized military personnel;
Total 33 7 26 8 adults (workers, officers, unemployed);
3 children under 14 years
Source: CISID (Centralized Information System for Infectious Diseases, Ministry of Health and Medical Industry)

Table 5. Strategy to contain the malaria outbreak in 1998–1999

Strategic approach Activitiesa
Eliminating the sources of infection • Timely case detection through ACD and PCD, followed by radical treatment
using chloroquine for 3 days and primaquine for 14 days. ACD was carried out
through daily house-to-house visits in all malaria foci, and was combined with
mass blood surveys among residents of the home villages and co-workers of
identified malaria cases
• Prompt and comprehensive investigation of every case and focus
• Interseasonal prophylactic treatment with 14 days of primaquine for all residents
of the active foci and others (army personnel, oil workers) who had been exposed
to the transmission risk
Integrated, evidence-based (i.e. • Full IRS coverage of all active foci
guided by foci investigations) vector • Larviciding (using mainly fish, and sometimes oil) to reduce mosquito density
control and longevity
• Reducing the number of breeding places through environmental measures
(mainly infilling of non-productive water bodies)
• Reducing human-vector contact through housing improvements
• Use of locally manufactured mosquito nets

Prevention for the population in the • Seasonal chloroquine prophylaxis during the malaria transmission season
foci • Health education
• Increased community awareness and engagement of the whole population in
malaria elimination and prevention
Source: Ministry of Health and Medical Industry
a. ACD = active case detection; PCD = passive case detection.

Eliminating Malaria | Achieving elimination in Turkmenistan | History of malaria and malaria control 11
2002–2003 outbreak In 2003, a total of 50 autochthonous cases of P. vivax
The second malaria outbreak in Mary province in malaria, as well as one imported case, were detected in
2002–2003 proved to be the last outbreak in Turkmenistan through passive and active case detection
Turkmenistan before certification of malaria-free status (PCD, ACD). Eight patients had clinical manifestations;
in 2010. Three districts of the province were primarily the rest (43) were reported as asymptomatic carriers,
affected – Yoloten, Serhetabad and Tagtabazar; the latter detected through ACD.
two border Afghanistan. Important lessons were learned All but two of the 50 autochthonous cases were
during this episode, as described below (18, 19). registered in four districts of Mary province – Yoloten
Analysis of data indicated that the index case of the (30), Tagtabazar (11), Serhetabad (4), Turkmen Gala (2) -
2002–2003 epidemic probably became infected at the and in Mary city (1); they included 43 adults and five
border with Afghanistan. The result was an outbreak children (17). Most cases (31/48) were detected among
in Yoloten, with secondary cases in other parts of Mary workers from oil and gas exploration companies; other
province (18, 19). The outbreak was detected in early population groups were affected only in Yoloten (15/30)
April 2003 when malaria was diagnosed in an oil and and Serhetabad (2/4) (Tables 6 and 7). Six cases were
gas worker living in Yashlyk farm (Dayhanbirleshik – detected through ACD among family members of
farmers’ association), Yoloten district, Mary province. malaria patients. The other two autochthonous cases
Infection had probably occurred in the previous year were detected in Ahal and Lebap provinces.
because the case was detected before the onset of the The intensified programme actions were successful:
2003 transmission season. Subsequent investigation the outbreaks were contained and the foci cleared up.
revealed that two housewives at the same farm had been The last four autochthonous cases in Turkmenistan
diagnosed with malaria during the 2002 transmission were registered in 2004. Three of these were detected
season, but that there had apparently been no follow-up in Mary province in February/March 2004 before the
action when these cases were reported. onset of the transmission season and probably resulted
Case detection and containment efforts were stepped from transmission during 2003. The fourth case was
up in 2003. A total of 16 brigades were engaged in detected in Ahal province in an area that is considered
conducting active case detection by daily house-to-house non-endemic; the patient had previously (in 2003) been
visits in all malaria foci in the villages; radical treatment in Tagtabazar, Mary province – an active malaria focus in
with chloroquine and primaquine of the patients 2003 – and the national programme reasonably assumed
detected with malaria; epidemiological investigation that the infection had been contracted there (18).
of cases and foci; full IRS coverage in all transmission
foci; larviciding; and raising of community awareness
regarding malaria.

Table 6. Distribution of cases detected in 2003 in Mary province by district and occupation
Districts Total cases Oil and gas workers Others

Yoloten 30 15 15

Serhetabad 4 2 2

Tagtabazar 11 11 0

Turkmen-Gala 2 2 0

Mary city 1 1 0

Total 48 31 17
Source: reference 18,19

12 Eliminating Malaria | Achieving elimination in Turkmenistan | History of malaria and malaria control
Table 7. Overview of malaria cases reported in 2003 in Mary province
Total malaria cases Patients with clinical symptoms: Parasite carriers detected through ACD:
in 2003:
49 6 43

Classification of 5 local
43 local
cases 1 imported from Afghanistan
Oil and gas workers – 2
Oil and gas workers – 29
Population Others – 4
characteristics Others – 14
(2 adults, 2 children aged 6 months
(11 adults, 3 children)
and 10 years)

Elimination of malaria, 2004–2010 The operations of the elimination campaign were

After the improvement in the malaria situation in broader in scope than those conducted during the
2004, and in line with the EURO malaria elimination epidemics and were applied nationwide. The strategic
strategy (9–11, 31–33), the Government of Turkmenistan directions of the national plan of action are summarized
decided to reorient the malaria programme towards in Table 8.
eliminating the last foci and preventing reintroduction. Case detection and management were given special
In 2005, the President of Turkmenistan signed the attention in the strategy. The peripheral general health
Tashkent Declaration – The Move from Malaria Control to services (including feldshers and the physicians and nurses
Elimination (9). There was strong political commitment of health houses) were central to the case detection
in the country to maintaining interruption of effort. Vigilance was reinforced throughout the country,
malaria transmission through large-scale elimination so that all patients with fever, anaemia and/or other
interventions aimed at improving the health of the suspect symptoms and/or with a suspect history of
people. An elimination strategy and a plan of action travel to malaria endemic country were examined for
centred on intense malaria surveillance were developed malaria as soon as they contacted the health services.
and implemented (34–36). In May 2007, a joint MOHMI– Active case detection was pursued through household
WHO meeting was organized in Ashgabat to launch visits in provinces affected in the recent past by malaria.
the malaria elimination campaign in Turkmenistan Visits were conducted weekly during the transmission
(Figure 6) (27). season and every 2 weeks out of season, even in urban
Figure 6. Participants of the MOHMI/WHO meeting areas, with blood sampling and examination of all febrile
on launching the malaria elimination campaign in
and suspected individuals.
Turkmenistan, May 2007, Ashgabat
In the following years, only cases imported from
endemic countries were reported: in 2005, 2006 and
2008 from Azerbaijan, Uzbekistan and Pakistan,
respectively (Figure 7). No malaria cases were registered
in 2009 or 2010 (12, 37). The country requested official
certification of its malaria-free status in 2009, and the
certification process was launched. The conclusion of
the first consultative mission of the WHO team for
certification of malaria elimination in Turkmenistan,
18–25 November 2009, was positive (38). A subsequent
certification mission of independent malaria experts
concluded that “the available data and information,

Eliminating Malaria | Achieving elimination in Turkmenistan | History of malaria and malaria control 13
observations and analyses indicate beyond reasonable Figure 7. Officially reported malaria cases in
doubt that malaria transmission in Turkmenistan had Turkmenistan, 2004–2010
4
been interrupted” and stated “with full confidence that

Number of reported cases

the national health system, as it is, will be able to prevent 3

the reintroduction of malaria to Turkmenistan” (19). In

2
2010, Turkmenistan was certified by WHO as a malaria-
free country (16, 17). 1

0
2004 2005 2006 2007 2008 2009 2010 2011
Years
Autochthonous Imported

Table 8. Strategic directions of the national plan of action for elimination of malaria in Turkmenistan, 2007
Strategic approach Sample activities
Case detection and management • Active and passive case detection
• Reporting, notification and registration in a national register
• Epidemiological investigation and classification of malaria cases and foci.
• Quality assurance of malaria laboratory diagnosis
• Radical treatment of malaria patients and parasite carriers
• Chemoprophylaxis for risk groups
• Cases and foci recording
• Data collection and analysis
Monitoring of determinants of the • Analysis of meteorological data
malaria situation • Analysis of sociodemographic situation (human migration, economic activities)
• Determination of the malaria potential and zoning of the territory by malaria
infection risk

Mosquito monitoring and control • Entomological surveillance of vectors and breeding sites
and operational research on vector • Hydro-engineering works and preventive supervision of the construction and
control operation of irrigation facilities
• Enhancement of the vector control measures that are safe for the environment
such as use of Gambusia larvivorous fish
• Provision of supplies to the population – locally manufactured bed nets and
repellents, to protect against mosquito bites
• Operational research on efficacy of larvivorous fish for vector control and
comparison with other vector control methods

Training of health personnel on malaria diagnosis, treatment, epidemiology, entomology and prevention

Public health education and community mobilization

Monitoring and evaluation of the effectiveness of the interventions undertaken

Interagency and intersectoral integration and coordination of antimalaria interventions

Active cooperation with neighbouring countries (Afghanistan, Islamic Republic of Iran and Uzbekistan) on malaria-
related matters – participation in cross-border meetings on malaria, exchange of information and planning of joint
activities
Source: Ministry of Health and Medical Industry

14 Eliminating Malaria | Achieving elimination in Turkmenistan | History of malaria and malaria control
Prevention of reintroduction, amounted to US$ 578 182. The strategic directions of
2010 onwards the national plan are summarized in Table 9. Compared
with the earlier elimination plan, (2007), the emphasis
In preparation for the certification of malaria elimination
shifted to prevention of malaria in travellers and of the
in 2010, Turkmenistan drew up a comprehensive
national plan for prevention of reintroduction. This is consequences of malaria importation into the country.
supported by MOHMI commitment and financing as No further indigenous cases have been reported in the
well as by intersectoral cooperation (39); state funding country despite continuing transmission in neighbouring
for prevention of malaria reintroduction in 2010 Afghanistan.

Table 9. Strategic directions of the national plan for prevention of reintroduction of malaria in Turkmenistan, 2010
Strategic approach Sample activities
Malaria surveillance • Early detection of each local and imported case
• Registration and timely mandatory notification of SES
• Epidemiological investigation of each malaria case and foci
• Strengthening EQA of laboratory diagnosis of malaria
Efficient case management • F ree examination and treatment services for malaria patients regardless of
citizenship and residency status
• Free malaria prevention services, including malaria chemoprophylaxis, for all
individuals arriving from, or leaving the country for, endemic areas
• Ensuring appropriate supply and stock of antimalaria drugs, equipment,
laboratory reagents and other reserves
Continuing vector surveillance • M
 onitoring of breeding sites and of major changes in environmental
activities parameters
Vector control activities • E
 nsuring availability of larvivorous fish hatcheries and distribution of fish in
Anopheles breeding sites
Strengthening cross-border • Developing cross-border collaboration strategy
collaboration • Conducting targeted activities jointly with representatives of neighbouring
countries (meetings, conferences, sharing of information and experience)
Maintaining malaria expertise • Upgrading training for specialists involved in malaria prevention
Maintaining epidemic preparedness • E nsuring appropriate supply and stock of insecticides in case of an outbreak
• Ensuring appropriate supply of antimalaria drugs
• Ensuring appropriate supply of laboratory reagents and consumables for
malaria diagnosis
Establishing routine epidemiological observation of the most at-risk groups such as seasonal workers, foreign
students, residents of border territories, military personnel and tourists
Malaria examination of students from endemic areas on their arrival
Scaled-up passive case detection and examination for malaria in case of fever
Improving operation of sanitary–quarantine points for the performance of anti-epidemic measures on the border
with Afghanistan and other neighbouring countries
Enhancing health education

Eliminating Malaria | Achieving elimination in Turkmenistan | History of malaria and malaria control 15
Factors contributing to changes in the
malaria situation, 1990–2010

Why did malaria re-emerge and an • foothills, where streams are natural breeding sites of
outbreak occur in the 1990s? An. superpictus and where agricultural development
Despite its elimination success in the early 1960s, may create additional water bodies suitable for
Turkmenistan continued to experience sporadic breeding;
malaria transmission in its southern border areas with • plains areas with suitable water bodies, such as occur
Afghanistan: at least 22 such cases were reported in in oases, irrigation areas and along canals and other
the period 1961–1969, isolated cases were reported in man-made water management systems.
subsequent years, and 25 autochthonous cases were The following factors contributed to the increased
reported in 1989–1990. Importation of parasites into the receptivity of some areas of the country:
country increased in the late 1980s with the return of
demobilized troops from Afghanistan, followed by the • Scaling up of construction and projects for
break-up of the former Soviet Union. exploitation of major water resources. In the 1980s
and 1990s, 18 large reservoirs were constructed in
As a rule, the likelihood of re-establishment of malaria the area near the Karakum Canal and river basins
transmission in any one area varies as a function of (8 on the Murghab River; 3 on the Tedzhen River;
vulnerability (parasite importation pressure) and 3 on the Atrek River; and 4 on the Karakum Canal);
receptivity (the likelihood that imported parasites will the extensive filtration ponds associated with these
be locally transmitted). If either of these two factors reservoirs became breeding places for anopheline
is zero, transmission will not occur. A retrospective mosquitoes. The density of malaria vectors
analysis of the situation in Turkmenistan shows that increased dramatically as a result of the intensive
there had been a gradual increase in both the receptivity breeding of Anopheles in filtration ponds.
and the vulnerability of the country during the
late 1980s. • Increased irrigation and expansion of the land
under rice cultivation. Land improvements for
Receptivity farming, especially for growing rice, as part of major
Receptivity is very low in the arid parts of agricultural irrigation projects led to increased
Turkmenistan (the Karakum Desert and areas in the receptivity, especially in Lebap and Dashoguz
north-western part of the country), and in practice provinces.
these areas have been always free of malaria. Highlands
Vulnerability
above 1500–2000 metres are also generally considered
malaria-free (14, 18, 19). Elsewhere, however, malaria The malaria importation threat for Turkmenistan came
vectors are still present, and the former malarious mainly from Afghanistan, now the only neighbouring
areas of the country remain receptive to resumption of country with endemic areas on its immediate border.
transmission. Turkmenistan’s border with Afghanistan also marked
the southern border of the former USSR. This area was
Relatively higher receptivity existed in the following therefore tightly controlled and population movements
areas (19):

Eliminating Malaria | Achieving elimination in Turkmenistan | Factors contributing to changes in the malaria situation, 1990-2010 17
were restricted. In the late 1980s, the time of dissolution were not promptly identified and properly treated,
of the USSR, vulnerability increased as a consequence of and vector density was not rapidly reduced, it can be
increased movement of infected populations (originating assumed that local transmission occurred not only in the
especially in Afghanistan). Military camps located near military camp but also among the local rural population.
Turkmenistan’s border with Afghanistan were also Moreover, demobilized soldiers with asymptomatic
at risk of infections that were transported across the infections imported malaria into other provinces. This
border by mosquitoes. The resulting increase of malaria summary underlines the importance of maintaining
importation in the 1980s and 1990s was followed by a both a high level of malaria vigilance and a system
rise of autochthonous cases. of malaria epidemic preparedness following malaria
elimination.
Analysis of the epidemiological information on the
outbreaks indicates that the two main contributing Why did an outbreak occur in
factors were: 2002–2003?
• Exposure of people living/working close to the The most probable source of infection for the
border (mainly military personnel and gas and oil autochthonous cases detected in July 2003 in Yoloten
workers) to bites by infected mosquitoes originating was the index case, a 27-year-old oil and gas worker and
from Afghanistan where malaria is still endemic. a resident of Yashlyk Farm in Yoloten district. He fell ill
This situation applies to Mary province where 50% twice – in July 2002 (hospitalized at the Yoloten district
of nationwide malaria autochthonous cases were hospital with a diagnosis of pneumonia) and in March
registered in 1999–2004 although there were only 2003 (hospitalized at the Yoloten district hospital again,
two imported cases. with acute fever) – yet was not examined for malaria on
• Introduction of malaria as a consequence of either occasion. A laboratory diagnosis of P. vivax was
importation by infected individuals. Lebap province not established until 8 April 2003, after the patient had
where 16 imported and 40 autochthonous cases been transferred to Ashgabat. In all probability, this was
were registered in 1999–2004 is a good example. a case of P. vivax relapse of an infection contracted in
2002. The person should have been considered to be at
Programme factors high malaria risk given his regular professional travel
close to the border with Afghanistan. In September and
Certain programmatic factors also played an important October 2002, malaria was diagnosed in two women
role in the deterioration of the malaria situation and the from Yashlyk Farm who had no travel history, yet no
spread of local malaria transmission. For many years specific actions were taken by malaria surveillance and
after elimination only isolated cases of malaria were general health services and only inadequate measures
detected, with no epidemiological consequences; the were applied. It is possible that this latter transmission
malaria surveillance system grew weaker as a result was overlooked by the local health facilities and
and was unable to respond in a timely manner to the therefore not reported to the central level. Only after
increased vulnerability and receptivity in the country. the diagnosis in Ashgabat in early April 2003 of relapsing
This was reflected in delayed diagnosis and treatment as vivax malaria in the Yoloten index case was a swift and
well as reporting, especially in rural areas. The comprehensive epidemic response started.
1998–1999 outbreak was recognized by the health
authorities only after a delay. In addition, there was a Subsequent epidemiological investigation and ACD in
lack of drugs (chloroquine and primaquine) to treat Mary province in April and May 2003 revealed another
the first cases, and an insufficient supply of insecticides 48 persons who had contracted malaria without being
for vector control interventions at the beginning of the detected and reported earlier. They included one
outbreak. As the first cases among military personnel acute malaria case and six asymptomatic cases among

18 Eliminating Malaria | Achieving elimination in Turkmenistan | Factors contributing to changes in the malaria situation, 1990-2010
14 members of the family of the index case. In addition, reported from the two south-eastern provinces: Mary
two more asymptomatic cases were detected in the same bordering Afghanistan, and Lebap bordering Afghanistan
village. Epidemiological investigation of settlements and Uzbekistan (Figure 8). Sixty (50%) of the
near the home of the index case revealed another eight autochthonous cases occurred in Mary province, while
asymptomatic carriers in the six villages of Bereket, more than one-third of local cases (51, 34%) occurred
Yashlik, Pagtachalik, Tokai, Atchapar and Rahat. Two of in Lebap province (Figure 9). Lebap was most affected
the infected persons were employees of the Ymambaba by malaria importation: more than half (54%) of all
branch of the oil and gas exploration company. Another imported cases were detected there (Figure 10; 18, 19).
11 employees of the same branch of the company were
identified as asymptomatic carriers in Yoloten on Enish
Figure 8. Total malaria cases by administrative
Farm and S. Niyazov Farm. The index case was a likely territory, 1999−2008
source of infection for his colleagues at the oil and gas 80
company as well for the other cases detected in the

Number of cases
60
district. However, it cannot be excluded that some oil
and gas workers may have contracted the infection while 40

working at the border. In all, 3535 persons at higher risk 20

were examined during the investigations. 0

Ashgabat Ahal Balkan Dashoguz Lebap Mary
Provinces
The epidemiological investigation of the outbreak
Source: reference 18
revealed that, in 2002–2003, a large number of oil
and gas workers were regularly moving between the Figure 9. Autochthonous malaria cases by
two vulnerable border districts (the Tore-Shih well in administrative territory, 1999–2004
4%
Tagtabazar district and the Berdiklich well in Serhetabad
6%
district) and the highly receptive Yoloten district, which 3%
4%
thereby also became vulnerable. The main office of the
oil exploration company was situated in the area of the Ashgabat
Ahal
rest house in Ymambaba, 15 km from the administrative 55% Balkan
centre of Yoloten. The total strength of the company Dashoguz
Lebap
was 610 workers, who worked 15-day shifts in the area Mary
33%
bordering Afghanistan.

Which populations were most

affected by malaria? Figure 10. Imported malaria cases by
administrative territory, 1999−2008
The most detailed epidemiological information is
available for the 150 malaria cases that were detected in 7%

Turkmenistan between 1999 and 2010. All cases were 20%

due to P. vivax.
Ashgabat
3%
As seen in Figure 1, the annual number of both Ahal
Balkan
indigenous and imported cases gradually declined over Dashoguz
Lebap
the period 1999–2010. A total of 120 autochthonous 13%
Mary
cases and 30 imported cases were officially registered. 54%

Most indigenous and imported cases (118, 79%) were 3%

Eliminating Malaria | Achieving elimination in Turkmenistan | Factors contributing to changes in the malaria situation, 1990-2010 19
The most affected age group were the 20–29-year-olds Control of the 1998–1999 outbreak
at 45% of the total (Figure 11). The majority of cases
were in males (85%) and in rural residents (78%) (18, 19). In 1998, in addition to the changed receptivity and
That a high percentage of the malaria cases occurred vulnerability some programmatic factors – delayed
in young adult males in rural areas is explained by diagnosis, treatment and reporting of malaria cases,
their occupations and worksites: the malaria outbreaks especially in rural areas – also played a role in the
affected military personnel (1998–1999) and oil and gas occurrence of the outbreaks. There was also a lack of
workers (2002–2003) – the only population groups to drugs (chloroquine and primaquine) to treat the first
regularly stay overnight in rural areas of Turkmenistan cases in 1998 and an insufficient supply of insecticides
close to the border with Afghanistan. Rural farming for vector control interventions at the beginning of the
communities who may occasionally visit the border outbreak. The subsequent rapid mobilization of the
areas were affected to a lesser extent and mainly in the specialized and general health services and the massive
course of local outbreaks. scaling up of control and surveillance activities in late
1998 and 1999 in the affected areas were ultimately
critical to containing the outbreaks.
Figure 11. Distribution of malaria cases by age
group, 1999–2008 An integrated approach brought about the prompt
50 containment of the outbreaks and clearing up of the
40 foci through a two-step process. The interventions that
30 immediately followed recognition of the outbreak,
%

20
implemented with the technical and financial assistance
10
of WHO, can be summarized as follows (14, 15):
0
12 14 67 21 23 9 4
• The risk groups were identified as the military
0-14 15-19 20-29 30-39 40-49 50-59 60
Number of cases/age groups (yrs)
personnel located close to the border with
Source: reference 18 Afghanistan, where the first malaria cases
were registered, and the population of nearby
settlements. The first interventions, concerned with
It is striking that many of the cases detected in 2003 eliminating the source of infection and interrupting
were reported as asymptomatic. This phenomenon transmission, were thus concentrated on the
was observed not only in the oil and gas workers military camp and surrounding villages.
who frequently stayed overnight in border areas but
also in the local population in the border areas with • Intensive case-finding, through daily house-to-
Afghanistan, making pre-existing immunity an unlikely house visits in affected areas and a mass blood
explanation given Turkmenistan’s long history of survey among military personnel and the local
very low malaria transmission. The seasonal timing population, allowed the sources of infection to
of the ACD could explain the absence of symptoms be identified. In 1999, in the initial focus in Mary
in some cases, since many infections could have been province, five new cases were diagnosed (three
in the clinical incubation stage, just before the start of among military personnel and two– a child and an
the transmission season. This may also have been a adult – in local residents) (Table 4). The scaled-up
reporting issue: the health staff who carried out ACD nationwide surveillance system led to the detection
may not have elicited, or reported, the full clinical of 26 additional cases in other provinces – the result
history for every person who was given a malaria of internal importation from the initial case – and of
diagnostic test during the outbreak investigation. two indigenous cases in Lebap province.

20 Eliminating Malaria | Achieving elimination in Turkmenistan | Factors contributing to changes in the malaria situation, 1990-2010
• Radical treatment of all detected patients – and provincial level with the financial assistance of
those with clinical symptoms and those with WHO.
asymptomatic infection – was carried out, enabling • During the transmission season, the SES carried
elimination of the sources of infection. out seasonal, weekly chemoprophylaxis with
• Comprehensive epidemiological investigation by chloroquine of 3000 fixed-term military personnel
SES of all cases and foci provided timely information stationed in the active malaria foci, as well as of the
for planning future activities in the malaria foci, approximately 6000 residents of active foci.
containment of the outbreak and prevention of the • Interseasonal (February-March) prophylaxis with
spread of transmission. primaquine (14 days) for the population of active
• Indoor residual spraying contributed to the foci was carried out under the strict supervision of
reduction of transmission in the new malaria foci. primary health care staff and SES.
• Reinforcement of entomological surveillance
A complex of activities was subsequently put in place, included: identification and mapping of all mosquito
including the following main interventions (14, 15): breeding sites within a 3-km radius of any affected
• Upgrading and capacity building of the SES staff settlement; identification of vector species and
– epidemiologists, parasitologists, laboratory development of a list of the main species in all areas;
technicians – were undertaken. Four lots of training and monitoring of mosquito bionomics and density.
on malaria surveillance, laboratory diagnosis and • Special provincial teams were established, appointed
control were conducted for 75 specialists, seminars by MOHMI decree, to carry out the following vector
for vector control staff were held in all regions, and control activities:
five additional positions were opened in the SES IRS of buildings in an area of 960 000 m2.
ŠŠ
parasitology department.
ŠŠ larviciding of surface water bodies in an area of
• Laboratories were upgraded. New microscopes, 960 000 m2.
reagents and consumables for malaria diagnosis
were provided to the main diagnostic centres by ŠŠ draining or infilling of all small and
WHO. economically unprofitable water reservoirs.

• Confirmation of all suspected malaria cases by • Large-scale health education was conducted.
microscopy became compulsory.
There was strict monitoring and supervision of the
• There was epidemiological investigation of all coverage and performance of all interventions by SES
confirmed malaria cases and foci using standardized and MOHMI.
epidemiological records.
• Reporting of malaria had been mandatory since Importantly, after containment of the outbreak, the
Turkmenistan was part of the USSR, so strict and activities of the national malaria control programme
timely notification and reporting were reinforced. were continued. Training and retraining of
epidemiologists, parasitologists, laboratory staff and
• Passive case detection and active case detection entomologists were conducted with technical assistance
(by regular household visits in affected areas) were from WHO. Efforts were made to keep the whole
scaled up. complex of surveillance and vector control activities, as
• Stocks of chloroquine and primaquine for the well as vigilance, at a high level, and a regular supply of
radical treatment of malaria patients and for antimalarial drugs and insecticides was maintained, with
chemoprophylaxis were provided to SES at national a stock being kept in SES at central and provincial levels.

Eliminating Malaria | Achieving elimination in Turkmenistan | Factors contributing to changes in the malaria situation, 1990-2010 21
Control of the 2002–2003 outbreak • Entomological investigation of foci in the territory
was carried out to reveal the presence of malaria
In 2002, it took an entire transmission season for Turkmenistan vectors.
to realize the seriousness of the renewed outbreak of malaria
in the country. Urgent interventions then followed the • All transmission foci were fully covered with IRS.
detection of the index case in early 2003 (18, 19). • Vector control activities were supported by
larviciding of 136 temporary and permanent
A total of 16 teams, comprising epidemiologists, mosquito breeding sites in villages and 26 breeding
parasitologists, entomologists, etc., were engaged in sites at the provincial headquarters of the oil and gas
the containment. They were assisted by three teams of exploration company, as well as labour camps near
laboratory technicians. The emergency interventions the oil and gas wells in the Afghanistan border area.
carried out upon recognition of the outbreak focused
on immediate blocking of transmission and can be • Public awareness was raised through lectures, mass
summarized as follows: media and other means.

• The activities for prompt case-finding concentrated The interventions undertaken were in time to largely
on the family members of the index patient, on the curb transmission: in 2004 only three cases occurred,
people at his place of work and on the residents of two of which were in children aged 11 and 16 years.
the village. In all malaria foci in the villages, daily Based on the date of detection, in February, of these
house-to-house visits with temperature-taking were cases, they could be attributed to the transmission
organized. The same activities were carried out in having taken place in 2003. Subsequently, refresher
the territory covered by the oil and gas exploration courses were organized for laboratory technicians and
company. orientation courses on malaria for the various categories
• Mass blood surveys were carried out and included of personnel engaged in implementation of antimalaria
the 602 oil and gas exploration workers and activities, including medical staff from Defence and
2566 villagers in Yoloten district, 189 persons in Border Guards. This complex of activities succeeded in
Serhetabad district and 178 people in Tagtabazar containing the outbreak and prevented exportation of
district. The surveys detected 48 additional cases that malaria outside Mary province.
were investigated and radically treated.
Elimination of malaria, 2004–2010
• All malaria patients and carriers were hospitalized
and received radical treatment with chloroquine and After the late detection and subsequent containment
primaquine, with follow-up for 2 years. of the Mary outbreak in 2003, MOHMI decided to take
action to strengthen the malaria control system. Priority
• All oil and gas workers and villagers of affected was given to strengthening malaria surveillance carried
settlements (1578 in Yoloten district, 347 in out through the primary health care services. From 2004
Serhetabad district, 1791 in Tagtabazar district) onwards, malaria elimination was tackled in a multi-
received interseasonal primaquine treatment and faceted manner, with considerable administrative skill,
seasonal chloroquine prophylaxis. sufficient government financing and continued political
• The comprehensive case investigations carried out support. This comprehensive approach was adopted to
by epidemiologists in the brigades contributed to eliminate the source of infection, reduce transmission
the timely identification of foci, comprehensive by vectors and provide health education and preventive
investigation, mapping, recording, and conducting of measures to the populations affected. The strategies,
interventions. interventions and supportive mechanisms are described
below.

22 Eliminating Malaria | Achieving elimination in Turkmenistan | Factors contributing to changes in the malaria situation, 1990-2010
Epidemiological surveillance and risk districts, for example, Serhetabad and Yoloten in Mary
control activities province, as well as Mary city, where ABERs in 2009 were
One of the early core activities of the elimination 6%, 13.7% and 7.3% respectively (Table 11), indicating that
programme was to strengthen and upgrade the existing the health facilities in these areas maintained high malaria
malaria surveillance system (Annex 7) and mechanisms, vigilance. Laboratory examinations related to the regular
so as to provide reliable information for programme household visits and epidemiological investigations of
management and reports of progress to key public health cases resulted in efficient case detection.
decision-makers, professionals and health care workers as Prevention of imported malaria and
a basis for evidence- based decisions on necessary action. its consequences

The backbone of the revitalized malaria epidemiological Once transmission had been interrupted, more attention
surveillance in the country was the document Guidelines was paid to identifying imported cases. Analysis
for the organization of malaria surveillance in Turkmenistan revealed the major role of imported malaria in the
(40), published in pursuance of Decree No. 137, dated epidemiology of malaria in Turkmenistan. The border
20 November 2005. Two additional guidelines for the with the highly-malaria endemic regions in Afghanistan
peripheral level were developed with WHO technical presented the greatest epidemiological risk and a
assistance: Malaria epidemiological surveillance protocol legislative and regulatory framework was developed to
(standard operating procedure – SOP) and the MOHMI’s address this issue. Special measures were undertaken at
Clinical protocol for malaria treatment and protocol for the border sanitary quarantine points, where medical
malaria epidemiological surveillance (41). The main aspects staff questioned all persons coming from Afghanistan
of these documents and the interventions undertaken in regarding their general health, fever, diarrhoea, etc.,
accordance with their guidance are summarized below. performed a brief clinical examination and checked
axillary temperature. Slides were taken from all
Special attention was given to ACD and PCD. Vigilance individuals with fever and with a history of recent fever.
was reinforced, so that all patients with fever, anaemia Details of all individuals who crossed the border in either
and/or other suspect symptoms and/or with a suspect direction were entered in a registry, and information on
history of travel were examined for malaria as soon the exact destination in Turkmenistan of each person
as they contacted the health services. Household was sent to the relevant district and to the national SES.
visits, allowing ACD, were carried out weekly during Health education on various disease risks, including
the transmission season and every 2 weeks out of malaria, was given to all those who crossed the border.
season, even in urban areas, with blood sampling and Transport vehicles were treated with insecticides.
examination of all febrile and suspected individuals.
At the Experimental Production Centre in Ashgabat,
Blood sampling for malaria was based mainly on clinical an outpatient consulting room on tropical diseases was
indications or on epidemiological indicators (a visit to established to provide medical advice, including malaria
a malaria-endemic country or to a local focus, family prevention, for travellers. For chemoprophylaxis against
members, neighbours or work colleagues of a case, etc.) P. falciparum, mefloquine, atovaquone–proguanil and
and this practice continues. Data show that blood sampling doxycycline are recommended.
in 2005–2009 was correctly targeted. The national annual
Management of disease
blood examination rate (ABER) was relatively low
(1.1–1.9%) for 2005–2009 but increased gradually over time The malaria treatment protocol is regularly updated
(Table 10) (19). However, in areas of high receptivity and according to WHO recommendations; the most recent
vulnerability – Lebap and Mary provinces – ABERs were update was issued in 2009 as Clinical protocol for malaria
higher, reaching 1.6% and 2.5% respectively and 3.7% in treatment and protocol for malaria epidemiological surveillance
Mary in 2009 (Table 10). Rates were highest in the high- (41). Vivax malaria was radically treated with chloroquine

Eliminating Malaria | Achieving elimination in Turkmenistan | Factors contributing to changes in the malaria situation, 1990-2010 23
and primaquine, as before, but the protocol reflected treatment of all patients remained free of charge. The
a policy shift from chloroquine to artemisinin-based regular provision of antimalarial drugs by the central level
combination therapy or quinine for the treatment of continued, and a stock of drugs was kept at central and
imported P. falciparum malaria. Hospitalization and provincial levels during the malaria elimination period.
Table 10. Annual blood examination rates by province and year, 2005–2009
Year Province Blood slides examined Annual blood examination rate (%)a
2005 Ashgabat city 4 186 0.7
  Ahal 8 084 1.1
  Balkan 727 0.2
  Dashoguz 4 242 0.4
  Lebap 16 702 1.6
  Mary 23 041 2
  Nationwide 56 982 1.1
2006 Ashgabat city 5 005 0.9
  Ahal 6 813 0.9
  Balkan 666 0.2
  Dashoguz 4 690 0.4
  Lebap 16 746 1.6
  Mary 24 753 2.1
  Nationwide 58 673 1.2
2007 Ashgabat city 6 929 1.2
  Ahal 6 862 0.9
  Balkan 608 0.2
  Dashoguz 5 259 0.5
  Lebap 16 750 1.6
  Mary 29 258 2.5
  Nationwide 65 666 1.3
2008 Ashgabat city 9 946 1.7
  Ahal 6 142 0.8
  Balkan 1 981 0.5
  Dashoguz 7 424 0.7
  Lebap 18 006 1.7
  Mary 32 025 2.7
  Nationwide 75 524 1.5
2009 Ashgabat city 12 131 2.1
  Ahal 8 909 1.2
  Balkan 3 806 0.9
  Dashoguz 9 239 0.8
  Lebap 16 277 1.5
  Mary 43 965 3.7
  Nationwide 94 327 1.9
Source: Reference 19
a. The rate was calculated on the basis of the provincial population figures, as follows: Ashgabat city – 569 438; Ahal – 741 852; Balkan – 405 463;
Dashoguz – 1 108 762; Lebap – 1 070 088; Mary – 1 171 631; Nationwide – 5 067 234.

24 Eliminating Malaria | Achieving elimination in Turkmenistan | Factors contributing to changes in the malaria situation, 1990-2010
Table 11. Annual blood examination rate in Mary province, 2009
Mid-year Annual blood
Locality Blood slides examined
population examination rate (%)
Mary city 128 056 9 418 7.3
Bayramaly city 53 306 3 642 6.8
Bayramaly 117 361 1 989 1.7
Wekilbazar 129 332 1 886 1.4
Garagum 43 982 770 1.7
Serhetabat 25 996 1 561 6
Yoloten 101 247 13 937 13.7
Mary 142 131 1 129 0.8
Murgap 119 976 1 768 1.5
Oguzhan 29 843 682 2.3
Sakargage 120 378 2 505 2.1
Tagtabazar 69 787 2 319 3.3
Türkmengala 90 236 2 359 2.6

Total  1 171 631 43 965 3.7

Source: reference 19

Field (epidemiological) investigations, as a discrepancy between the number of cases reported

recording and reporting, flow of annually to EURO and the information presented in the
information, data processing, analysis country report for certification in 2010, which may be
and use explained by the insufficient data collected during initial
The timely epidemiological investigation of every epidemiological investigations of some cases (12, 18, 19).
malaria case and focus was given particular attention Registers of malaria cases and foci were developed and
by the local SES parasitologists, epidemiologists and maintained at SES central and peripheral level. Detailed
entomologists through the completion of a special information on case definitions, each patient’s history,
unified recording form (Annex 8). The form includes examination, diagnosis and treatment, as well as on foci
basic but essential information that allows conclusions categorization and transition, was collected in those
to be reached about the place and time of malaria registers.
contraction. On the basis of epidemiological data
Vector (entomological) surveillance
collected, a case definition and focus categorization are
established according to WHO definitions (31, 33, 42, 43). The national territory and neighbouring areas were
All forms were kept at district SES, with copies being stratified by levels of receptivity according to the
sent to the central level. The foci were monitored and results of entomological monitoring. Entomological
classified and a focus “passport” was kept up to date – surveillance, carried out by the SES entomological staff,
focus recording form with mapping of every focus that was intensified not only in the areas of former outbreaks
was maintained by SES (Annex 9). A system for timely but also in all areas with higher malariogenic potential.
notification, reporting and recording was established A permanent record (“passport”) was established for
using standard reporting forms (malaria has been a each water body, with relevant maps, and was regularly
notifiable disease in Turkmenistan since Soviet times). and systematically updated. In risk areas there were
Analysing the reporting system during the development (still used nowadays) sentinel sites for adult mosquito
of this case-study revealed certain shortcomings, such monitoring, which was/is performed regularly in the

Eliminating Malaria | Achieving elimination in Turkmenistan | Factors contributing to changes in the malaria situation, 1990-2010 25
transmission season; if the mosquito density is high, province, a large area is targeted and totally covered;
larval control is strengthened. A database on Anopheles coverage in Dashoguz, which includes the Amu Darya
mosquitoes, their bionomics and density was maintained delta, needs improvement. At national level, more than
by district SES entomologists. 99% of areas targeted for larval control were treated by
fish; the use of oil was minimal. No chemical larvicides
Vector control activities
were used after the first malaria elimination in 1961
Vector control activities were designed to reduce: the life (18, 19).
span of female mosquitoes to less than the time required
for development of sporozoites (by IRS); larval density It is worthy of note that mosquito nets have been made
(by use of larvivorous fish or application of oil – no locally for generations and traditionally widely used;
specific chemical larvicides were used); and human- long-lasting insecticide-treated nets have not been
vector contact (by use of mosquito nets). Programme promoted in the country.
staff focused on reducing and preventing transmission in
Improvement in living standards and
residual or new active foci.
personal protection
Indoor residual spraying was carried out in case of an In recent years, living standards in Turkmenistan have
active focus or an epidemiologically worrying situation; improved. Better housing and the use of air-conditioning
a variety of pesticides were used, mostly pyrethroids (by about 50% of households, even in the villages)
(see Table 12). Stocks of insecticides were provided by may have contributed to the reduction in the country’s
the Government and maintained by MOHMI at central malaria risk.
and district levels.
In some districts the health services actively promote and
According to national reporting, there has been no IRS distribute a synthetic pyrethroid insecticide vaporizer,
since 2005 (18, 19) as there have been no more cases or Raptor®, which may also be helpful in reducing malaria
active foci in the country. The use of larvivorous fish, risk, although there is a lack of data. However, these
however, has continued. Turkmenistan has extensive devices may add to the selection pressure on anophelines
experience with larviciding (44) and uses several species to develop pyrethroid resistance, so routine monitoring
of larvivorous fish, especially Gambusia affinis, in water of insecticide resistance is increasingly important.
basins, including rice fields (Table 13). In high-risk Mary

26 Eliminating Malaria | Achieving elimination in Turkmenistan | Factors contributing to changes in the malaria situation, 1990-2010
Table 12. Indoor residual spraying activities, 2000
Households that Households actually
Coverage Insecticides used
should be treated treatedb
achieved
(%)
Provincea Number Area (m2) Number Area (m2) Insecticide Dose (g/m2) Amount
Propoxur 1 3l
Ashgabat 215 10 750 199 9 797 91.1 Fenthion 1 2.5 l
Cyfluthrin 0.05 0.2 kg
Propoxur 1 100 l
Ahal 4 761 357 075 4 667 350 000 98 Fenthion 1 50 l
Cyfluthrin 0.05 10 kg
Propoxur 1 90 l
Balkan 3 745 269 640 3 558 256 176 95 Fenthion 1 75 l
Cyfluthrin 0.05 4.6 kg
Propoxur 1 82 l

Dashoguz 3 822 324 870 3 707 315 095 97 Fenthion 1 93 l

Cyfluthrin 0.05 17 kg
97 Propoxur 1 151 l
Lebap 7 523 677 070 7 147 643 230 Fenthion 1 149 l
Cyfluthrin 0.05 17 kg
100 Propoxur 1 149 l
Mary 6 957 619 173 6 957 619 173 Fenthion 1 150 l
Cyfluthrin 0.05 16 kg
Total 27 023 2 258 578 26 235 2 193 471 97.2
Source: references 18, 19
a. Average household area is estimated as: 50 m2 in Ashgabat, 75 m2 in Ahal, 72 m2 in Balkan, 85 m2 in Dashoguz, 90 m2 in Lebap, and 89 m2
in Mary.
b. Two cycles of IRS (April, August) were conducted.

Eliminating Malaria | Achieving elimination in Turkmenistan | Factors contributing to changes in the malaria situation, 1990-2010 27
Table 13. Larval control by oil-based and biological larviciding, 2009

Treated
Surface of Surface of
Coverage with Treated
Anopheles Anopheles
oil-based with fish Note
reservoirs reservoirs (%) larvicides (ha)
Province targeted (ha) treated (ha)
(ha)

Ashgabat 65 65 100 4 61 Oil products

Ahal 19 19 100 - 19
Balkan Oil products
17 17 100 2 15 Alburnoides,
Poecilia reticulata
Dashoguz Grass carp,
938 398 42 - 398
Gambusia
Lebap Gambusia,
459 459 100 - 459
stone moroko
Mary Gambusia,
876 876 100 - 86 stone moroko,
Varicorhinus capoeta
Total 2 374 1 834 77 6 1 828
Source: references 18, 19

Health education activities

Figure 12. Examples of public health education
To increase community awareness and participation in products for community awareness work among
malaria prevention practices, a number of information, different population groups
education and communication (IEC) and behaviour
change communication (BCC) materials were developed
and handed over to SES for distribution to communities
(Figure 12). The emphasis of these materials was on
schoolchildren who can spread the information within
their families, military personnel and residents of
settlements situated near the border, i.e. the groups that
had been most affected by the epidemics and were at
risk of infection. Community awareness sessions were
conducted for inhabitants of the settlements found to
be active malaria foci, during which the printed IEC/
BCC materials were also distributed. The public health
IEC work, including malaria prevention issues, was also
channelled through school curricula and mass media.

A plan for preventing the reintroduction of malaria,

built on the experience accumulated during the process
of eliminating transmission, was also developed and
subsequently endorsed (39).

28 Eliminating Malaria | Achieving elimination in Turkmenistan | Factors contributing to changes in the malaria situation, 1990-2010
Capacity building been understaffed; some Russian specialists left the
The national malaria programme was coordinated and country and there was a loss of personnel. Once it
conducted by the Sanitary Epidemiological Service (SES) was understood that well-qualified personnel were
of MOHMI (for organizational details, see Annex 7), crucial for the success of the campaign, SES facilities
and especially: were upgraded.

• at national level by the Epidemiology and The malaria control programme benefited from an
Parasitology Department of the MOHMI and the upgrading of health facilities, including recruitment and
EPC, which includes a parasitology department with training of staff, provision of equipment and transport
a reference laboratory and an outpatient tropical (microscopes, computers, cars). A wide-scale continuous
disease clinic; education programme, reaching more than 1400 health
personnel, was instituted for training/retraining of
• by five provincial (velayat) SESs and one in the city malaria programme staff, including parasitologists,
of Ashgabat; and epidemiologists, laboratory specialists, entomologists,
• by 64 town and district (etrap) SESs. clinicians and general practitioners, over a 4-year period
(Table 14, Figure 13).
It should be noted that the parasitology departments
with a laboratory at provincial and district SES are In January 2010, the following SES staff were directly
responsible for the surveillance and control of all engaged in antimalaria interventions:
parasitic diseases, including malaria. • 44 parasitologists and 57 assistant parasitologists;

The general health services and other relevant ministries • 9 laboratory specialists and 54 laboratory assistants
and organizations were also involved in the activities with secondary medical education;
of the malaria programme. After the independence • 41 entomologists and 51 assistant entomologists;
of Turkmenistan in 1991, many of these bodies had • 193 spray operators.

Table 14. Number of malaria-trained health staff in different fields, 2005–2009

Number of malaria trained staff by years

Specialists in 2005 2006 2007 2008 2009 Total
Parasitology Higher education 33 41 29 34 45 182
Secondary education 52 61 44 59 55 271
Entomology Higher education 28 42 34 40 55 199
Secondary education 47 45 47 54 66 259
Laboratory Higher education 19 30 17 55 78 199
diagnostics
Secondary education 27 30 36 84 119 296
Total 206 249 207 326 418 1 406
Source: Ministry of Health and Medical Industry

Eliminating Malaria | Achieving elimination in Turkmenistan | Factors contributing to changes in the malaria situation, 1990-2010 29
Figure 13. Training course on laboratory diagnosis in Ashgabat, the national coordinator of the external
of malaria for the SES staff conducted by WHO quality assurance (EQA) system, was upgraded. In 2009,
EURO consultants, Ashgabat, 2008
Turkmenistan passed legislation – National Programme
for External Quality Assurance/Control (EQA/C) – on
laboratory diagnosis, which functions at all levels
according to the endorsed SOP Protocol for the external
quality control of malaria diagnostics. A programme to
further strengthen the quality of malaria diagnosis was
also developed during a round-table workshop, “Quality
Standards of Laboratory Tests”, organized by MOHMI
with support from WHO and held in Ashgabat in 2009.

The EQA/EQC involves double-checking 10% of all

negative slides (and, in principle, all positive slides, but
there had been none since the last case in 2008) at the
next higher level. In practice, this means that 10% of
slides examined at district- and hospital-level laboratories
are double-checked at the laboratories of the provincial
SES. Of the slides that are examined at provincial
SES laboratories, 10% are subsequently checked at
the national reference laboratory (NRL) of the EPC’s
parasitology department in Ashgabat.

In addition, there is supervision of laboratories. Every

laboratory is visited twice a year; the NRL laboratory
supervises the provincial laboratories, which in turn
supervise the lower-level laboratories. When necessary
the NRL supervises all laboratories.
Laboratory support for surveillance,
EQA/EQC The NRL participated successfully in an international
EQA scheme that involves:
Laboratory diagnosis of malaria was performed at
hospitals, outpatient facilities, polyclinics and laboratories • cross-checking of positive and some proportion
of the SES. By 2009, the country had 227 laboratories (usually 2–3%) of negative malaria slides examined
where blood was examined for malaria (18). in the NRL over a defined period (usually one
year) by an internationally accredited independent
A microscopy quality assurance system, involving diagnostic laboratory; and
double-checking of 10% of all negative slides and
confirmation of all positive slides at intermediate and • blind blood slides are sent to the NRL by the same
national levels, was introduced in Turkmenistan in internationally accredited independent diagnostic
Soviet times. However, in the years immediately after laboratory for making a diagnosis – presence of
the collapse of the Soviet Union, quality assurance malaria parasites, Plasmodium species and parasite
was not fully operational. This problem was addressed density. It is accompanied by a short epidemiological
during the containment of epidemics and the system and clinical story.
was subsequently strengthened and monitored by There is a complex evaluation of the quality of
MOHMI. The malaria reference laboratory at the EPC laboratory work, including the proportion of the correct

30 Eliminating Malaria | Achieving elimination in Turkmenistan | Factors contributing to changes in the malaria situation, 1990-2010
slide readings, quality of slide preparation and staining, • The Ministry of Fishery, on the establishment of
and formulation of results. On the basis of a score hatcheries of larvivorous fish.
system developed by the international laboratory, the NRL’s • Oil and gas companies, on the provision of waste oil
results are reported as a percentage score. If that score for larviciding of mosquito breeding sites.
exceeds 80%, the NRL receives a certificate for quality of
laboratory diagnosis of malaria, valid for one year. • Tourism agencies, on providing health advice on
malaria prevention, chemoprophylaxis and measures
Intersectoral collaboration to protect against mosquito bites to nationals leaving
for malaria-endemic countries.
The Government recognized that the problem
of malaria is one that goes beyond health alone • Construction companies and oil companies that
and that achievement of malaria programme import labour, on providing health information on
goals required the involvement of a variety of the risk of malaria, ensuring free access to diagnostic
institutions and agencies. In 2005, the Chairman of and treatment facilities for staff from malaria-
the Cabinet of Ministers of Turkmenistan therefore endemic countries, and maintaining high vigilance.
approved several documents governing intersectoral
Cross-border cooperation
collaboration; these addressed the structure of the
Interagency Coordination Committee, distribution As Turkmenistan borders malaria-endemic countries
of responsibilities between the various organizations, (Afghanistan, the Islamic Republic of Iran and
and plans of action. Uzbekistan), developing cross-border collaboration was
a top priority. The country took part in the cross-border
Related activities include collaboration with: meetings that were organized by EURO in Uzbekistan
• Provincial and district administrations (khyakimliks), (1999), Azerbaijan (1999, 2000) (26), Uzbekistan (2005),
for implementation of provincial/district malaria Tajikistan (2006), Afghanistan (2007), Turkmenistan
elimination action plans (early detection, diagnosis, (2007) (11) and Turkey (2008) (45). Representatives of
hospitalization and treatment, hydro-engineering the ministries of health of the three neighbouring
measures, establishment of fish hatcheries and malaria-endemic countries also took part in some of
introduction of fish into water reservoirs, sanitation those meetings (2005, 2007 and 2008) and the issues
in the inhabited localities, and public awareness of cross-border malaria risk and collaboration were
work). discussed. A cross-border cooperation meeting between
officials of the ministries of health of Turkmenistan
• The Ministry of Defence, in providing information and Afghanistan was held in 2009, with support from
on malaria cases to the MOHMI for inclusion in its WHO. Absolute commitment to the Tashkent (2005)
analyses. Declaration and the Kabul (2006) Declaration (Health for
• Immigration services, in providing detailed All, Health by All: Communicable Diseases Recognize
information to the Department of Parasitology No Borders) was emphasized, as was the determination
on people arriving in the country from malaria- to continue strategic partnership for malaria control
endemic countries. In early 2009, a “Health Care and elimination and to coordinate implementation of
and Migration” round-table discussion, organized antimalaria interventions (46, 47).
by MOHMI with support from the WHO Country
Office, was held in Ashgabat. The discussion was
attended by all national stakeholders: – health
care services, migration service, border service,
education, tourism, economic development, and the
mass media.

Eliminating Malaria | Achieving elimination in Turkmenistan | Factors contributing to changes in the malaria situation, 1990-2010 31
Legislation and regulation elimination (Table 15, Figures 13–15). In both years, an
To ensure consistency in policies and strategies and essential part of the allocation went to human resources
successful implementation of the malaria control and technical assistance, to ensure that parasitology
programme, MOHMI developed and issued – in personnel could maintain malaria surveillance at
2005, 2008 and 2009 – a number of specific decrees, a satisfactory level, even though their priority had
regulations and guidelines related to malaria elimination. now become surveillance of parasitic diseases other
(34–36, 39–41). All these documents were elaborated than malaria. Of the Government malaria budget
with the technical assistance of EURO and were in line for 2010, 11–20% was spent on staff training, a good
with WHO recommendations (9, 10, 31, 33, 42, 48–50). indicator of MOHMI efforts to maintain high levels of
The most important aspects of these documents are professional qualification. It should also be noted that
summarized above in the explanation of the different the Government budget covered activities of the Plan of
fields of interventions. Action to Prevent Re-Introduction of Malaria Transmission;
for example, there were allocations for maintaining
Cost of malaria elimination the stock of drugs, insecticides and diagnostics. Some
resources for communication and advocacy, as well as
Financial data for the Turkmenistan malaria elimination for monitoring and evaluation of activities, were also
efforts are available for the decade 2000–2010. The planned.
start-up financing of the Plan of action of prevention of
reintroduction of malaria is considered in these allocations. Apart from the contributions from WHO, the entire
Starting at about US$ 1 million in the year 2000, the malaria expenditure for 2009–2010 (US$ 1 095 301) was
Government budget increased to US$ 1.5 million covered by the Government.
by 2002 and continued to rise thereafter, exceeding
US$ 4 million per year in 2005–2006 (Figure 13). This
increase was related to the containment of the Mary Figure 13. State funding for malaria interventions
by year, 2000–2010
outbreak in 2003 and the subsequent elimination
activities of the national malaria programme. A total of 4

US$ 10.5 million from the national budget was allocated

USD (million)

3
for malaria elimination in 2005–2008. Over this period, 2
EURO provided in-kind technical assistance and support.
1
From 2007 onwards, the Government budget was
0
reduced, to end at around US$ 0.5 million in 2010, the 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Years
year the country was certified malaria-free. Expenditure Source: Ministry of Health and Medical Industry
per head of population started at US$ 0.22 per year in
2000, reached US$ 0.86 per year in 2005 and dropped
to US$ 0.10 and US$ 0.11 in 2009 and 2010 respectively
Figure 14. State funding for malaria interventions
(Figure 14). In 2009, there was also financial support
by year, per capita, 2000–2010
through the WHO country budget (US$ 300 000) for 1.0
planning, training, administration and overheads, 0.8
communication and advocacy, and monitoring and
USD

0.6
evaluation (Table 15).
0.4

A comparison of the Government budget breakdowns 0.2

for 2009 and 2010 shows that funding of malaria 0

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
surveillance activities was maintained after malaria Years
Source: Ministry of Health and Medical Industry

32 Eliminating Malaria | Achieving elimination in Turkmenistan | Factors contributing to changes in the malaria situation, 1990-2010
Figure 15. Government expenditure breakdown, 2010
0,4%
3,5% 1,3%
0,1%

19%
Human resources and technical assistance
Training
Insecticide and spraying materials (excluding distribution costs)
Diagnostics (excluding distribution costs)
Antimalarial medicines (excluding distribution costs)
3,2%
Infrastructure and other equipment
Communication and advocacy
6,4%
64% Planning, administration, overheads–government
2,1% Monitoring and evaluation

Source: Ministry of Health and Medical Industry

Table 15. Expenditure breakdown, 2009–2010

Expenditure (US$) by

Government WHO
Expenditure category 2009 2010 2009 2010
Human resources and technical assistance 441 883 368 236 - -

Training - 12 000 64 000 -

ITNs (excluding distribution costs) - - - -

Insecticide and spraying materials
- 36 742 - -
(excluding distribution costs)
Diagnostics (excluding distribution costs) 18 538 18 538 - -
Antimalarial medicines
56 698 112 339 - -
(excluding distribution costs)
Procurement and supply management costs
- - - -
(transport, fees, etc.)
Infrastructure and other equipment - 500 - -

Communication and advocacy - 2 058 25 250 -

Planning, administration, overheads - 20 210 52 600 -

Monitoring and evaluation - 7 559 171 492 -

Total 517 119 578 182 313 342 -

Source: Ministry of Health and Medical Industry

Eliminating Malaria | Achieving elimination in Turkmenistan | Factors contributing to changes in the malaria situation, 1990-2010 33
Lessons learned and drivers of change

From the late 1990s onwards, control population, formulated by Gromashevski, 1942 (51).
measures and socioeconomic development The aim was to eliminate the source of infection
in Turkmenistan have reversed the malaria by timely and complete case detection and radical
receptivity and vulnerability that had built treatment, by prompt and comprehensive investigation
up over the preceding decades. of every case and focus, as well as to control the vector
through reducing its density and longevity, the number
of breeding places and the extent of human-vector
Problems and constraints overcome
contact. The measures taken brought about prompt
After the elimination of malaria in 1961, malaria containment of outbreaks and clearing up of foci.
surveillance activities were given special attention
and maintained at a sufficient level for many years. In Several aspects of the Turkmenistan approach merit
the 1990s, however, the SES system failed to respond special mention:
adequately to the increased malaria receptivity and
vulnerability; a degree of neglect resulted in delayed • Intensive, active case-finding through daily house-
diagnosis of malaria cases, with subsequent outbreaks. to-house visits by mobile teams and primary health
Once this weakness was recognized, the SES promptly care facilities in all malaria foci, as well as mass blood
scaled up surveillance and control activities to contain surveys carried out among villagers and co-workers
the outbreaks, prevent further spread of malaria in the related to malaria cases, led to early detection
country and interrupt malaria transmission. and radical treatment of cases and thus to timely
elimination of sources of infection and limitation
Although malaria control and elimination in of local transmission. Regular household visits by
Turkmenistan were generally good, a shortage of the local primary facilities in active foci is a well-
qualified staff proved to be a challenge, especially at the established practice, with the aim of conducting ACD.
provincial and district levels of the SES network, with This approach, based on fever screening, is widely
many Russian specialists leaving the country after the used among EURO Region countries facing malaria
independence of Turkmenistan. Understanding the key problems, and was applied on daily basis during the
role of human resources, MOHMI upgraded its SES outbreaks, and once every one to two weeks in all
system and set about capacity building to fill the gap – active foci during the transmission season. Screening
new specialists were appointed and extensive training of the population at higher risk was also performed
was undertaken. (family members, population in the active foci,
co-workers of a case) and led to the detection of
Comprehensive strategies applied parasite carriers, especially in 2003. PCD is performed
Turkmenistan adopted a complex approach to malaria at primary level, usually by family doctors at health
control and elimination, combining scientifically sound houses who are well-informed about malaria. The
and evidence-based strategies, practices and tools. high level of vigilance towards malaria should be
The interventions were directed to the three main specially mentioned as well as malaria examination
components of the epidemiological process: the source of all febrile patients seeking medical assistance in
of infection, the mode of transmission and the healthy affected regions.

Eliminating Malaria | Achieving elimination in Turkmenistan | Lessons learned and drivers of change 35
• Significant success was achieved in reducing the is maintained for each water body; it is regularly
number of sources of infection through strictly updated and its status is reviewed weekly. Vector
monitored radical treatment of each case with control is well-designed and carried out through:
chloroquine and primaquine, as well as interseasonal larval control by physical measures (larvivorous
prophylaxis with primaquine and seasonal fish, or oil); IRS whenever an active focus or an
chemoprophylaxis with chloroquine for the population entomologically worrying situation is identified;
of active foci. These three interventions reduced the and use of locally produced (untreated) mosquito
likelihood of development of gametocytes in the nets. Air-conditioning and other personal protection
peripheral blood of people who had, or may have, measure are widely used. The last round of IRS was
been infected and thus of transmission. Disease carried out in 2005.
management is well set up in Turkmenistan; malaria • The outbreak control activities benefited greatly
treatment is free of charge and regular supplies of from temporary mobile teams of specialists
drugs are provided by the Government. (epidemiologists, parasitologists, entomologists,
• Through comprehensive case investigations, all clinicians and laboratory technicians) being assigned
new active and potential foci were identified and to conduct the urgent measures in affected areas.
investigated promptly, permitting appropriate This ensured a rapid response and good coverage
planning and the implementation of control and performance, including prompt case detection,
measures. Well-organized and efficient processing case and focus investigation, and IRS coverage.
of information by the SES provides timely case
registration and notification and regular flow of Upgraded and motivated NMCP
information to the upper levels of the system, as staff
well as a feedback loop back to lower levels. This National coordination of the malaria programme
enables rapid analysis of the situation and prompt, is the responsibility of the MOHMI State Sanitary
evidence-based decision-making by the responsible Epidemiological Service at national, provincial and
authorities. It should be stressed that case-based district levels. It is supervised by the Deputy-Minister
surveillance has been conducted in Turkmenistan of Health. Activities are conducted by SES, primary
for years. Epidemiological investigation of every health care services and other institutions, all of which
new case and focus is carried out by SES staff; a case played an integral part in the programme interventions.
record form is completed and a focus record form The existence of the specialized SES network, with
(“passport”) – with detailed information, mapping, substantial expertise in malaria control and elimination,
focus transition and classification – is maintained. All appears to have been a critical factor in achievement of
of this information is critical for the timely initiation the goals. Over the years, SES has proved to be a strong
of interventions if needed, and correct determination and reliable system for the surveillance and control of
of their type, scope and period of application. infectious and parasitic diseases, including malaria.
• Integrated vector control was guided by the results There is a strong laboratory support in the country.
of foci investigations, and included full IRS coverage Recently upgraded laboratories provided prompt and
and larviciding where appropriate. Entomological accurate parasitological diagnosis of malaria. A system
surveillance is conducted by SES. It includes annual of cascade training contributed to better professional
identification and mapping of all potential and qualifications among laboratory staff and improved
actual breeding sites, use of representative sentinel expertise in malaria diagnostic microscopy; rapid
sites for monitoring larval control, determination diagnostic tests have never been used because of the
of larval and adult densities, and identification of relatively low number of malaria cases and the existence
Anopheles species. A permanent record (“passport”) of reliable microscopic diagnosis. All malaria cases

36 Eliminating Malaria | Achieving elimination in Turkmenistan | Lessons learned and drivers of change
in Turkmenistan are microscopically confirmed. The containment. Turkmenistan also benefitted from a
internationally certified National Reference Laboratory WHO consultancy in developing strategies (National
of Parasitic Diseases Diagnosis is responsible for the Strategic Plan for Malaria Elimination in Turkmenistan
national EQA programme, cross-checking 10% of (2008–2010)), plans (National Plan of Action to
negative slides and confirming all positive ones, as Prevent Re-Introduction of Malaria Transmission
well as monitoring and evaluating the work of the in Turkmenistan for 2010–2015), and guidelines.
laboratories using a special check-list. As a participant Continuing financial and technical assistance was
in an international EQA programme, the NRL holds provided by WHO to help the country move towards
certificates for the good quality of laboratory diagnosis its stated elimination goals, and finally to certify the
of malaria. One of the key components of surveillance country as malaria-free. The concomitant EURO move
– namely, malaria laboratory diagnosis – was thus towards region-wide elimination provided an enabling
clearly reliable, meaning that delays, or failure, in the environment. Turkmenistan hosted the WHO Meeting
identification of cases were averted. on progress achieved with Malaria Elimination in the
WHO European Region with the participation of WHO
Strengthening collaboration and EMRO representatives in November 2007 (Figure 16).
community mobilization Achievements and experiences on malaria elimination
Turkmenistan undertook many activities to strengthen were reported and shared between countries and
intersectoral and international collaboration in the field regions.
of malaria, as well as to improve health education of Figure 16. Participants of the WHO EURO meeting
the population and community mobilization. on progress achieved with malaria elimination in
the WHO European Region, Ashgabat, 2007
Strong political commitment
The high level of political commitment to and
governmental support for the national malaria
programme are worthy of special attention. The
Government of Turkmenistan provided strong support
for the containment of the malaria outbreaks and
for malaria elimination efforts. Malaria control and
elimination interventions were supported by policies
and strategic plans, decrees and guidelines that were
endorsed by the Cabinet of Ministers and MOHMI.
Throughout, the activities of the national malaria
control programme were adequately funded, mainly by In conclusion we can say that all the systems and
the Government, and sufficient funding continues to be activities mentioned above indicate that in Turkmenistan
provided for prevention of the reintroduction of malaria. there is a strong NMCP that was able to promptly
contain the epidemics upon detection, and ultimately
WHO support interrupt resurgent malaria transmission. The national
Support from the WHO Regional Office for Europe health system, and in particular the well-organised
appears to have been important for the country peripheral surveillance system were, following some
in containing outbreaks and conducting a malaria initial lapses, able to respond comprehensively to
elimination programme. The prompt response with identified outbreaks and demonstrated a solid expertise
technical and financial assistance at the beginning in conducting antimalarial interventions.
of the outbreaks may well have facilitated the rapid

Eliminating Malaria | Achieving elimination in Turkmenistan | Lessons learned and drivers of change 37
Outlook for the future Drivers of change to take into account in the coming
years may be summarized as follows:
Factors that reduced the receptivity of once malarious
areas include durable solutions such as the permanent • The malaria potential (which combines information
infilling or draining of mosquito breeding sites, as on receptivity and vulnerability) indicates that wide-
well as higher living standards and the improvement scale reestablishment of transmission in the country
of human habitations. Factors that reduced malaria is unlikely; however, a higher epidemiological risk
vulnerability include the continuing strict control of persists in the areas bordering Afghanistan.
population movements on the border with Afghanistan, • The impact of malaria imported from other
the medical observation of people coming from countries on resurgence of local transmission is
Afghanistan by the border sanitary quarantine points currently minimal but might increase in the future,
staff with a special attention to febrile persons, and the for instance with increased population exchange
collaboration of the military and the oil and gas industry with the Indian subcontinent.
in the elimination efforts. Malaria risk in Turkmenistan’s
other neighbouring countries is declining dramatically, • The development of water resources is continuing,
further reducing the importation risk. In general, the and water surface areas of reservoirs may increase
number of travellers from other countries, including in some areas with the extension of the Turkmen
malaria-endemic countries, entering Turkmenistan has River and construction of the Altyn Asyr Turkmen
been very limited and this is reflected in the minimal Lake, which has extensive affluent drainage canals.
malaria importation in the past few years. Any delays in diagnosis and treatment of imported
vivax malaria in receptive territories, including the
Now that the local transmission of malaria has been settlements in the river valleys and oases, would
interrupted, all efforts are directed towards preventing mean a risk of malaria reintroduction in these
the reintroduction of malaria. Turkmenistan has geographical areas.
developed an appropriate plan of action and the relevant
activities are funded by the Government. It is crucial that
epidemiological surveillance of malaria is maintained
at a satisfactory level to ensure prompt detection and
treatment of cases, as well as timely response to any
emergency.

38 Eliminating Malaria | Achieving elimination in Turkmenistan | Lessons learned and drivers of change
Conclusions

This case-study demonstrates that malaria The experiences of Turkmenistan show the risks
resurgences can be reversed and malaria of programme slippage and inattention and prove
elimination ultimately achieved through that there are ultimately no shortcuts to the control
and elimination of malaria. The case-study also
strong political commitment; adequate
highlights the importance of continued funding for
funding (largely domestic); correct
malaria activities, even in the absence of ongoing
policies, strategies and guidelines; well- local transmission. Only in such an environment can
developed systems, especially laboratory the country maintain adequate vigilance and ensure
and surveillance; rapid response capacity; timely responses to potential changes in receptivity and
technical assistance; and – perhaps vulnerability, prompt detection of any malaria case,
most importantly – domestic human and preparedness for response actions when required.
resource capacity to run an intelligent Turkmenistan has an ongoing duty, not only to its
and comprehensive malaria control and own people but also to its neighbours, to maintain this
elimination programme. dedication to remaining malaria-free.

In Turkmenistan there is a strong NMCP that was able

to promptly contain the epidemics upon detection, and
ultimately interrupt resurgent malaria transmission.
The national health system, and in particular the well-
organised peripheral surveillance system were, following
some initial lapses, able to respond comprehensively to
identified outbreaks and demonstrated a solid expertise
in conducting antimalarial interventions.

Eliminating Malaria | Achieving elimination in Turkmenistan | Conclusions 39

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Eliminating Malaria | Achieving elimination in Turkmenistan | References 43

Annex 1: Data sources and methods applied

Data were collected from the following sources for this the Deputy Chairman of the Cabinet of Ministers
case-study: of Turkmenistan, Ashgabat (2005) (5).

• WHO ŠŠ SES reports, registers, etc.

Malaria-related materials in the WHO Registry • Scientific publications concerning malaria in

ŠŠ
and Archives collection of reports of technical Turkmenistan were identified using PubMed and
missions, records, reports of EURO meetings, Google and by screening scientific journals and
and other information on Turkmenistan up other sources.
to 2011 were reviewed. The following two • Authors’ materials and data collected during
documents were found to be especially useful various EURO technical support missions in the
sources of information: Elimination of malaria country.
in Turkmenistan. National report for country
certification (1) and Report on malaria control in Data on the number of malaria cases by Plasmodium
Turkmenistan (2). species, case category and year of reporting used in this
A literature review of WHO publications was case-study were based on information contained in the
ŠŠ
carried out. reports Elimination of malaria in Turkmenistan. National
report for country certification (1) and Report on malaria
ŠŠ Country data reported to WHO/HQ and to control in Turkmenistan (2) and on EURO’s Centralized
EURO as part of the annual reporting cycle, Information System for Infectious Diseases (CISID) (6).
including information submitted for the annual During the data processing, some discrepancies were
World Malaria Report, were reviewed. detected between cases number for the years 1999–2003
• Country data, including: reported by Turkmenistan to CISID (6) and those cited
Country publications and manuals. in the other two sources (1, 2). It was established that a
ŠŠ
more precise analysis of malaria cases had been made
ŠŠ MOHMI data − reports, laws, regulations, by the local malaria programme staff in preparing the
orders, guidelines, etc. National malaria control national report for country certification (1), so for these
programme documentation, reports, registers particular years analysis was based on the information
of cases and foci, maps, guidelines. in the national report and in Report on malaria control in
ŠŠ National Plan of Action to Prevent Re-Introduction Turkmenistan (1, 2).
of Malaria Transmission in Turkmenistan for
2010−2015, adopted by the Cabinet of Ministers All data collected were epidemiologically analysed, with
of Turkmenistan on 26 WOctober 2009 (3). the aim of characterizing the malaria situation in different
periods and the effect of interventions. Analysis used the
ŠŠ National Strategic Plan for Malaria Elimination in main epidemiological parameters and indicators such as:
Turkmenistan (2008−2010), approved by Decree of annual number of cases (autochthonous and imported);
the Deputy Chairman of the Cabinet of Ministers malaria morbidity and mortality; distribution of cases by
of Turkmenistan, Ashgabat (2008) (4). age, sex and other parameters; geographical distribution
ŠŠ The National Programme “Malaria Prevention in of malaria; number, category and transition of malaria
Turkmenistan, 2005−2010, approved by Decree of foci; parasites and vectors.

Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 1: Data sources and methods applied 45
References
1. Elimination of malaria in Turkmenistan. National 4. National Strategic Plan for Malaria Elimination in
report for country certification. Ministry of Health and Turkmenistan (2008–2010). Approved by Decree of
Medical Industry, Ashgabat, 2010. the Deputy Chairman of the Cabinet of Ministers
of Turkmenistan, Ashgabat, 2008.
2. Kondrashin AV, Schapira A. Report on malaria control
in Turkmenistan. Geneva, World Health Organization, 5. National Programme “Malaria Prevention in
2010 (WHO Registry file M50–370–62). Turkmenistan, 2005–2010”. Approved by Decree of
the Deputy Chairman of the Cabinet of Ministers
3. National Plan of Action to Prevent Reintroduction of Turkmenistan, Ashgabat, 2005.
of Malaria Transmission in Turkmenistan for
2010–2015. Adopted by the Cabinet of Ministers of 6. Centralized Information System for Infectious Diseases
Turkmenistan, 26 October 2009. (CISID). Copenhagen, WHO Regional Office for
Europe, available at: :http://data.euro.who.int/
cisid/.

46 Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 1: Data sources and methods applied
Annex 2: Demographic data from the United
Nations Population Division

Variable Year/period Value

Population (thousands) 2010 5.177

Population sex ratio (males per 100 females) 2010 97.1

Percentage aged 0–4 years 2010 10

Percentage aged 5–14 years 2010 19

Percentage aged 15–24 years 2010 21.6

Percentage aged 60 years or over 2010 6.1

Percentage aged 65 years or over 2010 4.1

Percentage of women aged 15–49 years 2010 56.4

Population growth rate (%) 2010–2015 1.25

Crude birth rate (live births per 1000 population) 2010–2015 20.8

Crude death rate (deaths per 1000 population) 2010–2015 7.4

Infant mortality rate (infant deaths per 1000 live births) 2010–2015 46.2

Life expectancy at birth, males/females (years) 2010–2015 62.4/70

References
1. Kondrashin AV, Schapira A. Report on malaria
control in Turkmenistan. Geneva, World Health
Organisation, 2010 (WHO Registry file M50–370–
62). (The 2008 revision population database (http://
esa.un.org/unpp/index.asp?panel=3))

Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 2: Demographic data from the United Nations Population Division 47
Annex 3: Administrative divisions, political
organization and economy

The national territory is divided into five provinces From ancient times, the country has had well-developed
(velayats), 25 cities and towns and 50 districts (etraps), agriculture based on irrigation, mainly cotton and
and villages (Figure 1). Apart from the cities, towns and rice growing, silkworm breeding, and cultivation and
villages, there are sparsely inhabited localities, such as processing of valuable commodities such as liquorice.
cattle-breeding farms in the desert, field stations, halts and Turkmenistan is among the world’s 10 major cotton
fishermen’s settlements (1, 2). producers.

Governance is based on the division of power between Water supplies for industry and, primarily, for
legislative, executive and judicial branches. The agriculture and farming are of major importance. To
Constitution of Turkmenistan determines the rights, satisfy these needs, Turkmenistan uses the waters of the
freedoms and responsibilities of the citizens of the Amu Darya – the largest Central Asian river – and other
country, foreign nationals and stateless persons. Supreme rivers, as well as the main artificial canals – Karakum and
state power and governance in Turkmenistan is exercised Turkmen Canals.
by the President, the Parliament, the Cabinet of Ministers
and the Supreme Court. The local authorities are References
comprised of representative and executive bodies.
1. Elimination of malaria in Turkmenistan. National
Turkmenistan has the fourth largest reserves of natural report for country certification. Ministry of Health and
gas in the world. It also has large reserves of oil, Medical Industry, Ashgabat, 2010.
iodine, bromine, sulfur and other minerals. Gas and oil
industries are leading branches of the economy. The 2. Kondrashin AV, Schapira A. Report on malaria
most developed sectors of national industry include fuel control in Turkmenistan. Geneva, World Health
and energy, chemistry and construction (1, 2). Organization, 2010 (WHO Registry file
M50–370–62).

48 Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 3: Administrative divisions, political organization and economy
Annex 4: Health care policies

In 1995, Turkmenistan adopted the State Presidential • improve the economic basis of the health care
Health Programme, intended to produce a radical system, create a health care service market and
improvement in health and an increase in life expectancy. encourage development of the private health care
In this connection, two important laws – On the Health delivery system;
Care of Citizens and On Pharmaceutical Activity and • increase the cost-effectiveness of the health care
Provision of Drugs – were adopted in 2002 (1, 2). services;
According to the Law On the Health Care of Citizens, the • strengthen the infrastructure of the health care
Government health policy aims to: system and develop the medical industry;

• ensure a single uniform state health care policy; • create favourable conditions for the work of the
health care facilities, irrespective of their type of
• recognize the right of the people to health care; ownership;
• design and implement state programmes for the • improve health education systems, training,
development and improvement of the health care retraining and advanced training systems for health
system (to meet the needs of the people); professionals and scientific researchers;
• advocate and promote healthy life styles; • improve the legislative framework of the healthcare
• strengthen human health and prevent diseases; system.
• provide for the sanitary, hygienic and
epidemiological safety of people; References
• ensure access to and free supply of the health 1. Elimination of malaria in Turkmenistan. National
benefits guaranteed by the State; report for country certification. Ministry of Health and
• provide effective, continuous and high-quality health Medical Industry, Ashgabat, 2010.
services;
2. Kondrashin AV, Schapira A. Report on malaria
• ensure social protection of citizens; control in Turkmenistan. Geneva, World Health
• provide people with the specific medicines to treat Organization, 2010 (WHO Registry file
and prevent infectious diseases, free of charge; M50–370–62).
• develop state voluntary health insurance and
improve health insurance systems;

Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 4: Health care policies 49

Annex 5: Main health indicators

Table A5.1 Main indicators on health economics in 2005

Indicator Value
External resources for health as percentage of total expenditure on health 0.3
General government expenditure on health as percentage of total expenditure on health 66.7
General government expenditure on health as percentage of total government expenditure 14.9
Total expenditure on health as percentage of GDP 4.8
Out-of-pocket expenditure as percentage of private expenditure on health 100
Per capita government expenditure on health at average exchange rate (US$) 104
Per capita total expenditure on health at average exchange rate (US$) 156
Private expenditure on health as percentage of total expenditure on health 33.3
Social security expenditure on health as percentage of general government expenditure on
6.1
health
Source: reference 1

A broad range of services is provided free of charge. The The main health indicators are shown in Table A5.2 (2).
size of, and procedure for, free health service provision
is determined by the Cabinet of Ministers. At present, Top ten causes of death data (Table A5.3) indicate that
all services related to communicable diseases, including the major burden in Turkmenistan comes from non-
malaria, are free of charge. communicable diseases (3).

Table A5.2 Health indicators according to WHO data for 2010

Indicator Value
Males: 60
Life expectancy at birth Female: 67
Both sexes: 63
Adult mortality rate (per 1000 adults 15–59 years, both sexes) 298
Under-5 mortality rate (per 1000 live births, both sexes) 45
Maternal mortality rate (per 100 000 live births) 77
Source: reference 2

50 Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 5: Main health indicators

Table A5.3 Top ten causes of death in Turkmenistan (2003)
Cause Total death (%)
1. Ischaemic heart disease 28
2. Hypertensive heart disease 12
3. Lower respiratory infections 9
4. Cerebrovascular disease 5
5. Tuberculosis 4
6. Cirrhosis of the liver 3
7. Diarrhoeal diseases 3
8. Perinatal conditions 2
9. Self-inflicted injuries 1
10. Diabetes Mellitus 1
Source: Reference 3

References
1. Kondrashin AV, Schapira A. Report on malaria control 3. Jakubowski E, Arnaudova A. 10 questions about health
in Turkmenistan. Geneva, World Health Organization, care in the countries of the Caucasus and Central Asia.
2010 (WHO Registry file M50–370–62). Copenhagen, WHO Regional Office for Europe, 2009.
2. Turkmenistan: health profile. Geneva, World Health
Organization, 2012, available at http://www.who.int/
gho/countries/tkm.pdf.

Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 5: Main health indicators 51

Annex 6: Parasites, vectors and geographical
distribution

In the past, three malaria species have been registered in An.(Ano.) barianensis ( James, 1911)
Turkmenistan: An.(Ano.) claviger (Meigen, 1804)
• P. vivax – in all areas; An.(Ano.) maculipennis (Meigen, 1818)
• P. falciparum – mostly, in Charjow (now Lebap) An.(Ano.) martinius (Shingarev, 1926)
province and Kara-Kala (now Makhtumkuly) district; An.(Ano.) plumbeus (Stephens, 1824)
and
An.(C.) multicolor (Cambouliu, 1902)
• P. malariae – in various areas.
The bionomics, distribution and epidemiological role of
Since 1960, P. vivax has been the only malaria parasite the three species that have been incriminated as malaria
known to be transmitted in the country. The last vectors in Turkmenistan are described below.
indigenous case of P. malariae was detected in 1988 Anopheles pulcherrimus
in a 76-year-old woman. Indigenous P. falciparum was This species prevails in the lowlands of
eliminated before 1960, probably in the late 1950s. Single Turkmenistan, especially in areas subject to flooding
cases of P. falciparum importation from Africa were from rivers and in the Karakum Canal zone. Its
observed in 1980 and in 1981 in Lebap, and two cases population dynamics closely follow the dynamics
in Ashgabat in 1988. In 1982, one falciparum case was of water vegetation. The main breeding sites are
imported to Bayram Aly from Afghanistan. No secondary Murgab, Tedjen and Etrek water storage reservoirs,
cases occurred in any of these instances (1). drainage systems and relict lakes (Yaskha, Topyatan,
The important malaria vectors are Anopheles pulcherrimus Garategelek, Ketdeshor, Ainokol and Akrabat).
and An.superpictus. A third vector, An.hyrcanus possibly The optimal temperature for larval development
plays a minor role in certain circumstances (1–3). In is in the range 30–35°C but temperatures up to
all, 11 species of the genus Anopheles, belonging to the 42°C are tolerated. Third-stage larvae overwinter in
subgenera Anopheles (Ano.) and Cellia (C.), have been reservoirs that are not bottom-frozen. The first adult
recorded in Turkmenistan: mosquitoes appear in April; numbers grow gradually
and peak in July. Densities remain high through
An.(C.) pulcherrimus (Theobald, 1902) September and up to mid-October in Esenguly and
An.(C.) superpictus (Grassi, 1899) Etrek districts. During daytime, mosquitoes choose
An.(Ano.) hyrcanus (Pallas, 1771) to stay in cattle-sheds, animal tents, weeds, shrubs,
pits and dry ditches. An.pulcherrimus is the main
An.(Ano.) algeriensis (Theobald, 1903) malaria vector in the plains of Turkmenistan.
An.(Ano.) artemievi (Gordeev et al., 2005)

52 Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 6: Parasites, vectors and geographical distribution
Anopheles superpictus in open outdoor water bodies. Adult mosquitoes
This species is abundant in mountainous and are hydrophilic and rest in thickly vegetated habitats
submontane regions. Larvae inhabit creeks, puddles, near their breeding sites. The species is of minor
marshlands along small stone-bed rivers, streams and importance as a malaria vector because of its
springs; overflows of aryks and kahrizes (irrigation exophilic and exophagic habits.
ditches); and boreholes with clear well-warmed Areas of malaria receptivity are the foothills, where
water containing calcium salts. In running water streams are natural breeding sites of An.superpictus
and deep reservoirs, such as the karst lakes of and where agricultural development creates additional
Köýtendag and the bathing pool in Germab, larvae suitable water bodies, as well as plains areas with suitable
are found in bunches of hair-like nematodes and water bodies, such as occur in oasis and irrigation
thickets of aquatic plants. Larvae also live in warm areas and along canals and other man-made water-
sulfurous springs in various districts, including management systems.
Ejery, Uzynsuw, Janahyr, Parhay, Archman, Kovata
and Berzengy. The optimal temperature for larval Large areas with an arid climate, such as the Karakum
development is 30–35°C, but larvae can survive in Desert and some regions in the north-west of the
water up to 40°C. In the Kopetdag Mountains, this country, where few people live, have always been malaria-
species is found as high as 2000 m above sea level free. Highlands above 1500–2000 m are also generally
and in Köýtendag up to 2500 m. The first larvae are considered to be malaria-free (1, 2, 4).
observed in April; peak numbers are registered in
the hottest months ( June to August), when there are After the elimination of malaria in 1961, most of the
numerous breeding sites in the stone-beds of small cases were registered in the southern provinces bordering
rivers after the water level in the mountain rivers Afghanistan – Mary and Lebap – known for their high
falls, and when water ponds appear as a result of level of receptivity (foothills, oasis areas, water bodies)
irrigation. From early October onwards the larval and vulnerability (cross- border population migration).
population slumps because of the mass retreat of
the female mosquitoes to hibernate. The endophilic
References
An.superpictus is the main vector in the mountainous 1. Elimination of malaria in Turkmenistan. National
and submontane parts of Turkmenistan. report for country certification. Ministry of Health and
Anopheles hyrcanus Medical Industry, Ashgabat, 2010.
This species is recorded in almost all districts. Its 2. Kondrashin AV, Schapira A. Report on malaria control
density is greatest near lowland rivers and the in Turkmenistan. Geneva, World Health Organization,
Karakum Canal, water storage reservoirs and lakes. 2010 (WHO Registry file M50–370–62).
Larvae inhabit marshlands with aquatic plants;
irrigation and drainage-collector systems; filtration 3. Zvantsov AB, Ejov MN, Artemiev MM. Malaria
ponds of dams and canals; and rice fields. Adult vectors in CIS countries. Copenhagen, WHO Regional
mosquitoes leave their winter hibernation places Office for Europe, 2003.
in mid-March and populations peak in May. In the
summer months, larvae disappear from the open 4. Amangel’diev KA. Current malaria situation
outdoor reservoirs but survive in shaded reservoirs in Turkmenistan. Meditsinskaia Parazitologiia i
with dense vegetation, at an optimal temperature of Parazitarnye Bolezni, 2001, 1:37–39 [in Russian].
25–30°C. In September-October, larvae appear again

Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 6: Parasites, vectors and geographical distribution 53
Annex 7: Organization of malaria control/
elimination within the structures of MOHMI

Ministry of Health and Medical

Industry of Turkmenistan

SSES Experimental State Sanitary Epidemiological Service (SSES)

Production Centre Department of Epidemiological Surveillance MOHMI Primary Health
- Parasitology Department and Parasitology Care Department
• National Reference Laboratory
• Office for Tropical Medicine
- Immunology Department Health
information
centre

Provincial SESs:
Health care departments in
Ashgabat city SES Ahal
Ashgabat city and provinces;
Balkan
Provincial primary health care
Dashoguz
facilities
Lebap
Mary

District
and city hospitals (64), rural
Town and district SESs (64 administrative units)
and urban health houses

54 Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 7: Organization of malaria control/elimination within the structures of MOHMI
Annex 8: Standard form for malaria
and other communicable diseases case
investigation

Name of institution: Geokdepe Etrap SES

Epidemiological investigation card no. 1 of infectious disease case/focus: Malaria

__________________________________________________________________________________

I. Patient data

1. Final diagnosis: first-time detected tertian malaria

2. Parasite type, species: P. vivax
3. Patient: local resident  traveller 
4. Name: Annamyradov Gochmyrat
5. Sex: male  female 
6. Date of birth: 18.10.1983
7. H
 ome address: Geokdepe etrap, Kopetdag Street No. 26
locality: urban  rural 
8. Place of work, study, no. of child education institution: Telephone Communication Unit, Technician
9. Date of last attendance at place of work, study: 20.10.2004
10. Health facility at place of residence: Geokdepe Hospital
11. Notification of the case received (date, time): 20.10.2004 (brief message) 10:30 am
oral (by telephone)  written 
12. Referral from (institution): Patient presented personally at etrap hospital
13. Emergency notification diagnosis: malaria?
14. Main symptoms at early stage of disease: headaches, chills, high body temperature
15. Patient detected: t hrough prophylactic examination 
epidemiological survey 
seeking professional health care 
16. Date and time of epidemiological investigation: 21.10.2004
Date of observation completion: 4.11.2004

Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 8: Standard form for malaria case investigation 55
 19. Date of
17. Date of onset of 18. Date of seeking diagnosis and of 20. Date of 21. Date of final
disease medical care emergency case hospitalization diagnosis
notification
12.10.2004 20.10.2004 21.10.2004 20.10.2004 21.10.2004

22. Place of hospitalization, transportation: Ahal Velayat Isolation (infectious disease) Hospital
23. Patient allowed to stay at home (reason): absence of epidemiological indications 
absence of clinical indications 
lack of hospital beds 
declined hospitalization 

24. Reason for late hospitalization: absence of epidemiological indications 

absence of clinical indications 
lack of hospital beds 
delay in seeking medical care 
delayed diagnosis 
declined hospitalization 
25. Laboratory examination: performed  not performed 
26. Diagnosis confirmed

Result of
Only clinically Date
investigation
1
bacteriological test 2
microscopic examination 3 21.10.2004 P. vivax
By laboratory examination
serological test 4
biochemical assay 5
Other methods 6

27. Date of last immunization (scheduled, by epidemiological indications, date, dose, drug, series):
Vaccination: Re-vaccination:

Missing data:
Patient vaccinated:
according to normal at wrong intervals between at wrong interval other violations of
schedule vaccinations after disease immunization schedule
Patient not vaccinated:
because of medical
because of refusal for other reasons
indications

56 Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 8: Standard form for malaria case investigation
II. Identification of infection source and transmission factors

28. Approximate date of infection: from 2003 to

29. Unusual circumstances or setting that might have affected the patient’s infection: patient did military service in the
malaria focus
Time period or
Circumstances or setting Location, address
date
Staying in a different inhabited locality Tagtabazar 2003—2004
Visit to relatives, family
Construction, agricultural or other work outside usual place of
residence
Recreation in natural environment (tourism, hunting, fishing,
swimming, etc.)
Recreation in a summer camp, summer cottage
Stay in hospital
Blood or plasma transfusion
Medical manipulations (specify)
Contacts with animals (birds)
Water supply pipeline or sewerage damage
Other

30. Persons who might have been sources of infection (patients or suspected cases; convalescents, infection
carriers, donors):
Diagnosis and clinical Place, time and nature
Examination/investigation
Full name form of disease of contact;
results
(or donor ship) address of donor

31. Information about food and water consumed by patient that might have contributed to this disease (record
only most probable factors):
Quality reported
Name of food; type Date and place of Date and place of Conditions of
by patient or by
of water source purchase consumption storage
other persons

Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 8: Standard form for malaria case investigation 57
Sanitary and hygienic characteristics of local foci related to this patient
A. By place of residence
32. Living conditions: separate apartment  
private house
room in a communal apartment  hostel 
hotel  boarding-house  other 
33. Density of occupation: 6 persons per room of m2.
34. Water supply: water pipe  water pump 
well (borehole, mineshaft) (communal, private)  imported water 
open water reservoir 
Quality of water (as reported): satisfactory
Regularity of supply: permanent supply
35. Type of excreta disposal: sewerage system  cesspit 
outhouse latrine  other (specify) __________________

36. Waste disposal: refuse chute  sanitation car  garbage recipient 

garbage container  other ________________

37. Sanitary status of: dwelling: satisfactory grounds: satisfactory toilet facility: satisfactory
38. Pediculosis: no Other insects: no Rodents: no
39. Other factors conducive to disease:

B. By place of work, study, education, rest and recreation, treatment

40. Name of organization and its organizational unit (shop, class, group, etc.) to which patient belongs _________
____________________________________________________________

41. Compliance with sanitary and hygienic standards and anti-epidemic requirements:

density of occupation____________________________________________________

isolation_______________________________________________________________

water supply___________________________________________________________

sewerage______________________________________________________________

sanitary maintenance____________________________________________________

food storage___________________________________________________________

food cooking___________________________________________________________

42. Factors conducive to disease_____________________________________________________

58 Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 8: Standard form for malaria case investigation
 43. Laboratory examination of materials collected from environment (including arthropoda):

Name of object: arthropoda or animal No. of Type and result of

Date Material
species samples examination

44. Specific and other types of prophylaxis of these persons (at the place of residence):

Reported to Follow-up prophylaxis Laboratory examination

Examination
and date of Date
Date Drug Dose Series Date Result result
report received

III. Interventions to eliminate the focus

45. Observation of persons who were in contact with the patient or who could be infected in the same settings:

Place and nature Immunization Type of restrictive

Name Age Address
of work data measures

46. Measures of specific prophylaxis and examination of persons in organized groups:

Laboratory
Detected

detection
Subject to Received

Date of
Name of No. of examination
Address specific specific
group contacts No. of Asympto-
prophylaxis prophylaxis Date Sick
persons matic

Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 8: Standard form for malaria case investigation 59
 47. Measures taken to interrupt infection transmission in foci:

Frequency of measures Implementation control

Measures type; drug At place of At place of Implementers (incl. laboratory) and
residence work, etc. results
Quarantine
Current
disinfection
Final
Siperator Daily Daily A. Charyev S. Berdyev
disinfection
Disinsection

Patient hospitalized in: Ahal Velayat Isolation (infectious disease) Hospital

IV. Epidemiological investigation conclusions

1. Infection occurred in the territory of: Turkmenistan

2. Province: Mary 3. District (city): Tagtabazar

4. Inhabited locality (district, town): urban  rural 

5. Most probable place of infection:
recreation center

group, rest and

Place of work

Summer child

Construction

(military service)
Public eating

environment

Other places
educational
Specialized

labor camp
Pre-school

institution
Unknown

In-patient
residence

En route
hospital
Place of

Natural
facility
School

01 02 03 04 05 06 07 08 09 10 11 12 + 13
6. Probable source of infection:

Human (full name) Animal (species)

Source unidentified

Patient with acute

Domestic animals
Infection carrier
form of disease

chronic form of

Convalescent

Wild animals
Patient with

Rodents
disease

patient

Other
Birds

01 + 02 + 03 04 05 06 07 08 09 10

60 Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 8: Standard form for malaria case investigation
 7. Probable food factor of infection transmission:

Water

Cottage cheese

Meat products
Drinks, juices

Fish, seafood
Cream, sour

Other dairy
products
cream
Milk
reservoir
Unidentified

waste
piped

open
well
01 02 03 04 05 06 07 08 09 10 11 12
Other ready-to-

Animal vectors
Blood, plasma,
Social contact
transmission

transmission

transmission
Respiratory

Animal raw
Cooked hot

serve foods

vegetables,

(mosquitoes)
products
berries

factors
Fruits,

serum
Salads

Other

Other
foods

13 14 15 16 17 18 19 20 21 22 + 23

8. Conditions related to infection:

Untimely Breaking Breaking of

Conditions detection and the rules of Untimely other rules of Visit to
Over density
undetermined isolation of disinfection immunization antiepidemic natural foci
the source regime regulations
01 02 03 04 05 06 + 07

Breaking the rules of sanitary regulations in

Other circumstances
supply and sewerage
Damages of water

Neglect of private
hygiene rules
manufacturing of

maintenance of
transportation
food products

food cooking

systems
instruments
sale of food
storage and

handling of
processing

premises
products

raw stuff

08 09 10 11 12 13 14 15 16 + 17

9. Disease in the focus:

A. At the place of residence: initial:  successive: 

B. At the place of work, study, education, recuperation, treatment: initial:  successive: 

Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 8: Standard form for malaria case investigation 61
 Investigation conducted by: S. Berdlev, A. Charyev, S. Toporov
Date of card submission to the health statistics office: 26.10.2004

Signatures:

Epidemiologist S. Berdyev
Assistant epidemiologist A. Charyev
Other specialists S. Toporov

62 Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 8: Standard form for malaria case investigation
Annex 9: Malaria focus record form
(“passport”)

City, district: Tagtabazar Etrap

1. Name of focus (inhabited locality): Tagtabazar Settlement
2. Closest inhabited localities related to focus: Gyzyl Gojaly land plot
3. Attendant healthcare facility: House of health in Tagtabazar
4. Vector species: Anopheles superpictus
5. Description of area and population:

1. Receptivity: rural  urban 

altitude, main geographical features, etc: Elevation above sea level is 450 m. Population – 11 910 persons, about 35%
of them children. There are 450 households. This inhabited locality has two permanent water reservoirs, 0.8 ha and 5 ha
2. Vulnerability: Inside endemic region; close proximity to endemic region; near border with Afghanistan
3. Population migration patterns: large numbers of temporary workers; presence of travellers from malaria-endemic
countries, etc.
6. Geographical map of focus: focus and focus boundaries; location of health facilities; mosquito breeding sites marked for
presence/absence of vector larvae; locations of households with registered malaria cases during past three years

7. Malaria cases in the focus by months

Number of malaria cases in the focus by months

Year Population Total
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1999
2000
2001
2002
2003
2004 1

Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 9: Malaria focus record form (“passport”) 63
8. Schematic map of the focus

Map of Tagtabazar Settlement

October Farm
Gyzyl Gojaly land plot

2,5km Sandy Kachy Farm 2km

Water reservoir; total area 5 hectares

1km

Water reservoir stays wet until

the beginning of the hot season when it dries out

9. Registered malaria cases in the focus by parasite species:

Malaria cases by Plasmodium species

Year Total
P. vivax P. falciparum P. ovale P. malariae Mixed
1999
2000
2001
2002
2003
2004 1 1

10. Distribution of malaria by age groups:

Number of malaria cases by age groups (years)

Year Total
0–1 2–4 5–9 10–14 15–19 Above 19
1999
2000
2001
2002
2003
2004 1

64 Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 9: Malaria focus record form (“passport”)
11. Distribution of malaria cases by sex:

Males Females
Year Total
Number % Number %

1999

2000

2001

2002

2003

2004 1 100

12. Distribution of malaria cases by population cohorts:

Year Total Number of malaria cases by population cohorts

number Non- Organized School Farm Workers Employees Housewives
organized children students workers
children
1999
2000
2001
2002
2003
2004 1

13. Number of blood slides for malaria testing:

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Total

Year
Passive

Passive

Passive

Passive

Passive

Passive

Passive

Passive

Passive

Passive

Passive

Passive

Passive
Active

Active

Active

Active

Active

Active

Active

Active

Active

Active

Active

Active

Active

1999
2000
2001
2002
2003
2004 1

Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 9: Malaria focus record form (“passport”) 65
14. Method of malaria case detection:

Number of malaria cases

Year Total
Active case detection Passive case detection
1999
2000
2001
2002
2003
2004 1

15. Detection of malaria cases by time between onset of disease and seeking medical care:

Malaria cases detected by interval between the beginning of disease and seeking
Year medical care (days) Total
1–3 4–7 8–14 15–30 >30
1999
2000
2001
2002
2003
2004 1

16. Time between seeking medical care and malaria diagnosis:

Time until diagnosis (days)

Year Total
1 2 3 4 5 6
1999
2000
2001
2002
2003
2004 1

66 Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 9: Malaria focus record form (“passport”)
17. Time between malaria diagnosis and hospitalization:

Time between diagnosis and hospitalization (days)

Year Total
1 2 3 4 5 6
1999
2000
2001
2002
2003
2004 1

18. Interseasonal primaquine chemoprophylaxis:

No. of persons No. of persons

Population Coverage Drug name Completion
Year subject to covered with Start date
size (%) and dose date
chemoprophylaxis chemoprophylaxis
1999 66346
2000 67216 10 000 10 000 100 primaquine 01.10.2000 14.10.2000
2001 68340
2002 69334
2003 70210
2004 71338 3 680 3 360 90.8 primaquine 01.10.2004 14.10.2004

19. Seasonal chemoprophylaxis:

No. of persons No. of persons

Population Coverage Drug name Completion
Year subjected to covered with Start date
size (%) and dose date
chemoprophylaxis chemoprophylaxis
1999
2000
2001
2002
2003
2004

Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 9: Malaria focus record form (“passport”) 67
20. Dynamics of the foci status:

Number of foci of the following categories

Year Residual Residual non-
New potential New active Cleared Restored
active active
1999
2000
2001
2002
2003
2004 1
2005 1
2006 1
2007 1

21. Indoor residual spraying (residential and non-residential premises):

No. of
No. of Sprayed area
Year Insecticide Date of IRS sprayed Coverage (%)
households (m2)
households
1999
2000
2001
2002
2003
2004 Siperator June 450 450 100 110

22. Anophelogenic water reservoirs in, and within 3 km of, the inhabited locality, and larvicidal interventions:

Total
Type of Number of Date of
Total area Gambusia- Date of oil Total oil-treated
anophelogenic anophelogenic Gambusia
(in hectares) introduced treatment area (ha)
reservoir reservoirs introduction
area (ha)
Permanent
Temporary
Rice field

68 Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 9: Malaria focus record form (“passport”)
23. Sanitary and hydro-engineering interventions:

Total area of Total area

No. of Eliminated Total area of eliminated
drainage and of cleared
anophelogenic anophelogenic anophelogenic
irrigation drainage and
Year reservoirs of reservoirs of no reservoirs of no
canals that irrigation
no economic economic importance economic importance
need clearing canals
importance
Number % Area (m2) % (m2) Area (m2) %
1999
2000
2001
2002
2003
2004

24. Measures for personal protection:

(a) Use of insecticide-treated nets

Population coverage in Total number of

Year Number of households Population
absolute figures mosquito nets used
1999
2000
2001
2002
2003
2004

(b) Use of non-treated nets

Population Total number of mosquito nets

Year Number of households Population
coverage (%) used
1999
2000
2001
2002
2003
2004 450 11 671 98

Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 9: Malaria focus record form (“passport”) 69
Remarks

The malaria focus record form is to be completed by the parasitologist/epidemiologist and the entomologist for
an inhabited locality in which at least one malaria case has been registered in the past three years. The form is to be
duplicated in the computerized database.

Parasitologist/epidemiologist: J. Kurbangeldiyev

Entomologist: Date 18.11.2004

70 Eliminating Malaria | Achieving elimination in Turkmenistan | Annex 9: Malaria focus record form (“passport”)
This case-study is part of a series
of malaria elimination case-studies
conducted by the World Health
Organization (WHO) Global Malaria
Programme and the University of
California, San Francisco (UCSF),
Global Health Group. The case-
studies series documents the
experience gained in eliminating
malaria in a range of geographical
and transmission settings with the aim
of drawing lessons for countries that
are embarking upon elimination.

For further information please contact: ISBN 978 92 4 150430 0

Global Malaria Programme

World Health Organization
20, avenue Appia
CH-1211 Geneva 27
Web: www.who.int/malaria
Email: infogmp@who.int