“Timely actions resulted in a sharp decrease in malaria incidence": an interview with Dr Kholmirzo Davlatov

Dr Kholmirzo Davlatov is the Director of the State Institution "Republican Tropical Diseases Center” within the Ministry of Health and Social Protection in the Republic of Tajikistan

The key to malaria elimination is universal access to health care. To what extent has Tajikistan managed to ensure access to health care for all?

Primary health care in the Republic of Tajikistan is organized according to the principle of family medicine. The entire national population, regardless of geographical location, has access to quality medical care that is delivered to all residents through 2908 primary health-care facilities, 523 public sector health facilities and 578 private facilities. As of January 2022, there were 21 170 physicians (20.4 per 10 000 of population) and 61 383 other health workers, including nurses, (58.9 per 10 000 of population) providing medical care throughout the country.

Are the National Malaria Control Programme authorities concerned about the resurgence of malaria in areas bordering Afghanistan? What measures and strategies are in place to mitigate these risks?

Ensuring sustainable entomological surveillance and control of malaria vectors is our primary strategy for preventing the return of local malaria transmission in areas that have been cleared of the disease. This includes areas bordering on Afghanistan where imported cases are a concern. We also employ timely measures to identify and track malaria patients and parasite carriers, and follow their treatment and hospitalization trajectories.

Pursuant to Order No. 606 of the Ministry of Health and Social Protection of the Population, the Ministry routinely conducts epidemiological surveillance of malaria and takes blood samples from all patients with a body temperature in excess of 37.5o to determine the causative agent of malaria.

In areas that are highly susceptible and vulnerable to possible resurgence, we mandate entomological surveillance of malaria vectors, while monitoring mosquito breeding sites and their resistance to insecticides. Water management activities are focused on sustainably improving the rational planning of hydraulic engineering and reclamation projects, and colonizing reservoirs where Anopheles breed with mosquito-eating fish. We also spray residential premises with residual-effect insecticides.

It should be noted that we have local Centres for Tropical Disease Control in all areas along the Afghanistan border. Our 2019–2023 national strategic plan to prevent the return of malaria transmission in Tajikistan calls for conducting annual vector control activities along the border to control for the importation of malaria-carrying mosquitoes. A new 5-year plan will soon be crafted to cover the time period of 2023–2028.

All persons arriving from Afghanistan are subjected to a malaria parasitological examination. Every year for World Malaria Day on 25 April, we coordinate a public information campaign about malaria prevention. As part of this campaign, the populations living in the border settlements are examined for malaria.

Over the years, the Government's policy of eliminating malaria and preventing its re-emergence has seen its share of ups and downs. Can you briefly describe some of the critical points where this course was tested and what difficulties were overcome?

Since the late 1990s there was an increase in the incidence of malaria in Tajikistan. The timely adoption of 3 national malaria control strategies, spanning from 1997 to 2015, not only helped to contain the spread of the disease but facilitated the complete elimination of local malaria in 2014, which is when the last case was reported.

In 2000, there was a sharp increase in the incidence of Plasmodium vivax and Plasmodium falciparum malaria and 19 064 cases were detected. Experts from the Tropical Disease Control Centres, which had by then been organized in every region, took all necessary measures to actively identify patients, hospitalize them in a timely manner, treat foci, conduct proper epidemiological surveillance, and carry out informational and educational activities. These timely actions resulted in a sharp decrease in malaria incidence within 2 years, bringing the caseload down to 6160.

Approximately 14 million doses of COVID vaccine have been administered in Tajikistan since the pandemic began. Has the Ministry of Health combined COVID testing/vaccination with malaria testing/tracing/antimalarial administration? Has the pandemic stepped up action against malaria or, on the contrary, hindered it?

COVID testing and vaccination did not jeopardize our malaria control efforts because regardless of COVID testing, all patients with suspected fever were screened for malaria.

During the pandemic, health care workers intensified their house-to-house visits to actively identify patients with fever, which simultaneously increased the number of people screened for malaria. Malaria chemoprophylaxis was not carried out in parallel with COVID vaccination, but all segments of the population over 18 were immunized according to indications.

Tajikistan's main exports are rice and cotton, but irrigation systems in these industries often create breeding grounds for mosquitoes. Can you describe what water and irrigation management practices have been put in place to reduce the number of such breeding areas? How did these efforts fit in with the efforts of the National Malaria Control Programme?

The most radical method for eliminating malaria outbreaks is preventing the formation of mosquito breeding sites. Through our National Malaria Control Programme, we focus on a variety of sanitary and water management activities in the rice and cotton-growing regions.

Working in partnership with the Ministry of Energy and Water Resources, our hydraulic engineering measures include draining and backfilling water bodies unnecessary for agriculture, and cleaning drainage networks, water collectors and water bodies in districts with a high risk of malaria.

At the same time, we have made widespread use of biological methods to eliminate mosquito larvae. In rice plantations and reservoirs favourable to the development of Anopheles, we have introduced the use of the mosquito larvae-eating fish, Gambusia. This biological prevention method has proven to be highly effective, and as a result, there has been a sharp decrease in the Anopheles mosquito population in the protected areas.

What collaboration is taking place between the National Malaria Control Programme and military units to ensure that border guards deployed along the Afghan border are tested and treated as part of active malaria case-finding strategies?

The National Committee for Coordinating AIDS, Tuberculosis and Malaria continues its work. The committee is comprised of representatives from such government departments as the health sector, tourism, migration, the Committee for the Protection of the National Borders, and others. Joint activities are managed with the in-house medical services of the Border Forces Directorate and focus on controlling malaria vectors, screening personnel for malaria, and holding seminars on malaria prevention.

Every border post has a medical officer or paramedic assigned to be in close contact with the Regional Tropical Disease Control Centres, which are equipped with rapid testing kits, slides, and blood lancet devices. Patients suspected of having malaria must provide a blood specimen that is sent for laboratory testing at a Tropical Disease Control Centre.

If the result is positive, an epidemiological investigation of the case is conducted at the border post, followed by a series of antimalarial and anti-mosquito measures carried out by the Centre’s personnel and experts. If a positive case is detected, the patient is then admitted to a military hospital for treatment.

At certain times of the year, in order to assess the reliability of the absence of local transmission of malaria, studies are carried out along the border with a special focus on border guards. Similar studies conducted in 2015, 2019 and 2021 detected no positive results.

What important lessons or experiences can you share with other countries working toward eliminating malaria?

Tajikistan’s historical data indicates that as a result of large-scale antimalarial measures, malaria had been eliminated as a mass disease by 1960. Only isolated foci remained within a 3-kilometer zone from the floodplain of the Amu-Darya and Pyanj Rivers, usually opposite the Afghan border settlements where possibility of transmission of malaria could not be ruled out.

After achieving such success, malaria stations were subsequently disbanded and the number of parasitologists, laboratory assistants, entomologists and disinfectors were reduced. Thus, during the malaria epidemic that hit in the early 1990s, there was a shortage of trained and experienced malaria control staff and it was difficult to carry out antimalarial activities at the local level.

During this period, the Ministry of Health was compelled to educate and train specialists in the field of malaria surveillance and control via international and national training courses and seminars. The Ministry had to rebuild and relaunch activities at specialized antimalarial institutions and establish national and provincial level Tropical Disease Control Centres, with special attention paid to districts with a high risk of malaria transmission.

Preventive and anti-epidemic malaria measures were launched within the framework of national programmes. Strategic plans were financed from the state budget and supported by grants from a number of international organizations. As a result, Tajikistan was able to eliminate malaria.

What is one of the most concerning challenges Tajikistan needs to address to prevent resurgence?

One of the most pressing tasks currently facing health services in Tajikistan is improving the existing system of epidemiological surveillance of malaria, intensifying our vigilance, and preventing the importation of the disease and its consequences.

In order to maintain the current malaria situation and prevent the disease from re-emerging in Tajikistan, we need to fortify the capacity of the Tropical Disease Control Centres and the parasitological departments of the health and epidemiological surveillance centres.

When carrying out anti-mosquito measures, and depending on the focality and occurrence of vectors, we have learned that we must pay special attention to the type of malaria landscape at hand. The application of a full-range of anti-mosquito measures are not always appropriate in certain environments so targeted actions caan often be more effective while also saving money.